CLM-2026-006230
Lakeside Regional Medical Center, Emergency Medicine. Service 2026-06-03 at emergency room (POS 23). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Sandra Barnes
- Member ID
- UHC-80935-12
- Date of birth
- 1941-11-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429196
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2499
- Coverage period
- 2025-05-01 to present
- Deductible
- $249.85 of $3,500.007%
- Out-of-pocket maximum
- $3,002.94 of $10,500.0029%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7132870750
- Network
- In network
- Rendering NPI
- 7132870750
- Location
- Miami, FL · TIN 25-1370713
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $624.00 | $343.20 | $343.20 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $173.00 | $95.15 | $0.00 | $95.15 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,726.00 | $949.30 | $0.00 | $949.30 | Paid |
| Totals | $2,523.00 | $1,387.65 | $343.20 | $1,044.45 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-747588
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-018491 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-03: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 29 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 Regional Medical Center (7132870750). | |
| 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 Regional Medical Center2026-06-03 10:05
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-747588.pdf6 pages
Itemised statement totalling $2523.00 across 3 lines.
- Er reported_report_PA-747588.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020390 | 2026-05-31 | Valley Internal Medicine Associates | $111.00 | 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.