CLM-2026-033693
Lakeside Medical Group, Family Medicine. Service 2026-01-24 at office (POS 11). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Ralph Hoffman
- Member ID
- UHC-55886-66
- Date of birth
- 1983-12-26
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-423969
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6503
- Coverage period
- 2021-01-01 to present
- Deductible
- $1,171.80 of $2,500.0047%
- Out-of-pocket maximum
- $1,239.50 of $10,000.0012%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 2278920733
- Location
- San Diego, CA · TIN 83-7560587
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $211.00 | $130.82 | $20.00 | $110.82 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $215.00 | $133.30 | $0.00 | $133.30 | Paid |
| Totals | $426.00 | $264.12 | $20.00 | $244.12 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-439991
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009368 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-24: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 8 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 | Pass | In-network provider Lakeside Medical Group (3911891331). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-01-24 11:29
Patient seen for hyperlipidemia, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-02-01 02:11
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-439991.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.