CLM-2026-008453
Lakeside Regional Medical Center, Emergency Medicine. Service 2026-06-08 at emergency room (POS 23). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Diane Jimenez
- Member ID
- UHC-27043-63
- Date of birth
- 1995-10-22
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427885
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3328
- Coverage period
- 2021-02-01 to present
- Deductible
- $31.36 of $500.006%
- Out-of-pocket maximum
- $239.84 of $1,000.0024%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 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 / REF631466
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $137.00 | $75.35 | — | — | PendedIDQ |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,645.00 | $904.75 | — | — | PendedIDQ |
| Totals | $1,782.00 | $980.10 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-651282
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001926; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-08: CORE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 12 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 Center2026-06-08 12:07
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
Attachments
Documents received with the claim
- Itemized billitemized_PA-651282.pdf7 pages
Itemised statement totalling $1782.00 across 2 lines.
- Er reported_report_PA-651282.pdf5 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001926; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.