CLM-2026-011246
Lakeside Medical Group, Internal Medicine. Service 2026-09-05 to 2026-09-07 at inpatient hospital (POS 21). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Andrea Russell
- Member ID
- UHC-80771-28
- Date of birth
- 1985-03-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-401396
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4012
- Coverage period
- 2022-01-01 to present
- Deductible
- $119.86 of $500.0024%
- Out-of-pocket maximum
- $59.76 of $1,500.004%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 3448373225
- Location
- Tampa, FL · TIN 85-1984822
- 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 | $230.00 | $126.50 | $126.50 | $0.00 | Paid |
| Totals | $230.00 | $126.50 | $126.50 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-435766
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-05 to 2026-09-07
- 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-029815 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-05: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 22 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 Group2026-09-07 13:56
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-435766.pdf2 pages
Itemised statement totalling $230.00 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
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.