CLM-2026-007576
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-04-20 to 2026-04-21 at inpatient hospital (POS 21). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Sara Carr
- Member ID
- UHC-76869-45
- Date of birth
- 1982-05-24
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-405833
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1863
- Coverage period
- 2021-05-01 to present
- Deductible
- $137.90 of $1,000.0014%
- Out-of-pocket maximum
- $1,147.61 of $3,000.0038%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 9694799328
- Location
- Los Angeles, CA · TIN 18-5876521
- Authorisation / referral
- none / REF263598
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 | $251.00 | $138.05 | $138.05 | $0.00 | Paid |
| Totals | $251.00 | $138.05 | $138.05 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-937796
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-20 to 2026-04-21
- 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-030120 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-20: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 37 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 (6644545769). | |
| 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 Associates2026-04-21 18:11
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-937796.pdf3 pages
Itemised statement totalling $251.00 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-2026-014404 | 2026-06-29 | Riverside Bone and Joint Center | $12,546.00 | 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.