Professional claim · CMS-1500 · EDI 837P
CLM-2026-033580
Lakeside Medical Group, Family Medicine. Service 2026-01-20 at office (POS 11). Received 2026-02-10.
DeniedOut of network
Billed
$455.00
2 lines
Allowed
$204.75
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Alexis Harper
- Member ID
- UHC-57014-87
- Date of birth
- 1954-04-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401123
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3693
- Coverage period
- 2023-07-01 to 2026-01-19
- Deductible
- $1,394.05 of $2,500.0056%
- Out-of-pocket maximum
- $3,265.98 of $10,000.0033%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3004199154
- Network
- Out of network
- Rendering NPI
- 6958511621
- Location
- Atlanta, GA · TIN 59-2183874
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $227.00 | $102.15 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1,2 | $228.00 | $102.60 | — | — | DeniedCO27 |
| Totals | $455.00 | $204.75 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-843141
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012080 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-20 is after coverage terminated on 2026-01-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-01-20 10:13
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-02-10 06:45
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-10 11:38
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-01-20 is after coverage terminated on 2026-01-19. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018118 | 2026-08-05 | Evergreen Internal Medicine Associates | $313.00 | Denied |
| CLM-2026-026026 | 2026-07-16 | Pinecrest Medical Group | $350.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.