CLM-2026-006273
Lakeside Medical Group, Internal Medicine. Service 2026-06-17 to 2026-06-19 at inpatient hospital (POS 21). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Jerry Perkins
- Member ID
- UHC-63351-43
- Date of birth
- 1988-01-07
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-428308
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1672
- Coverage period
- 2025-11-01 to present
- Deductible
- $778.77 of $3,500.0022%
- Out-of-pocket maximum
- $1,343.20 of $14,000.0010%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 5305258662
- Location
- Tampa, FL · TIN 85-1984822
- Authorisation / referral
- none / REF984437
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 | $254.00 | $139.70 | $139.70 | $0.00 | Paid |
| Totals | $254.00 | $139.70 | $139.70 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-250801
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-17 to 2026-06-18
- 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-007345 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-17: CORE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 30 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 (3228212296). | |
| 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 Group2026-06-19 12:22
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-250801.pdf9 pages
Itemised statement totalling $254.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012166 | 2026-07-10 | Canyon Reference Lab | $182.00 | Denied |
| CLM-2026-000040 | 2026-06-04 | Riverside Bone and Joint Center | $312.00 | Approved |
| CLM-2026-024403 | 2026-01-05 | Riverside Internal Medicine Associates | $204.00 | Denied |
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.