CLM-2026-009389
Lakeside Medical Group, Internal Medicine. Service 2026-05-20 to 2026-05-21 at inpatient hospital (POS 21). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Keith Vazquez
- Member ID
- UHC-01356-46
- Date of birth
- 1965-05-23
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-403711
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1196
- Coverage period
- 2024-07-01 to 2026-07-01
- Deductible
- $248.62 of $500.0050%
- Out-of-pocket maximum
- $587.70 of $2,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 2143231852
- Network
- In network
- Rendering NPI
- 7003553113
- Location
- Houston, TX · TIN 29-4552150
- 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 | $198.00 | $108.90 | — | — | Review |
| Totals | $198.00 | $108.90 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-847782
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-20 to 2026-05-21
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012139 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-20: MEDICARE-ADV-B (MA), effective 2024-07-01, terms 2026-07-01. | |
| Timely filing | Pass | Received 24 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 (2143231852). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for type 2 diabetes mellitus with hyperglycemia. Note dictated; signature pen”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-05-21 09:45
Patient seen for type 2 diabetes mellitus with hyperglycemia. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-14 04:30
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-14 08:01
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-847782.pdf9 pages
Itemised statement totalling $198.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for type 2 diabetes mellitus with hyperglycemia. Note dictated; signature pen”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003319 | 2026-10-06 | Unity Dermatology Clinic | $760.00 | Denied |
| CLM-2026-034579 | 2026-09-09 | Lakeside Medical Group | $508.00 | Denied |
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
Development letter outstanding.