CLM-2026-004750
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-06-26 to 2026-06-27 at inpatient hospital (POS 21). Received 2026-08-10.
Member
Resolved through the identity graph
- Member
- Juan Murphy
- Member ID
- UHC-80089-58
- Date of birth
- 1973-10-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-409167
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1277
- Coverage period
- 2024-08-01 to present
- Deductible
- $1,303.76 of $3,500.0037%
- Out-of-pocket maximum
- $3,659.61 of $14,000.0026%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6735813951
- Network
- In network
- Rendering NPI
- 2368904464
- Location
- Denver, CO · TIN 58-6102170
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $213.00 | $117.15 | $117.15 | $0.00 | Paid |
| Totals | $213.00 | $117.15 | $117.15 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-622232
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-26 to 2026-06-28
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016812 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-26: CHOICE-PLUS-PPO (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 44 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 Internal Medicine Associates (6735813951). | |
| 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 Internal Medicine Associates2026-06-27 11:23
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-622232.pdf8 pages
Itemised statement totalling $213.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026862 | 2026-08-09 | Harbor Diabetes Center | $574.00 | Approved |
| CLM-2026-024490 | 2026-06-14 | Northgate Medical Group | $516.00 | Approved |
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
Clean claim, priced at contract rate.