CLM-2026-017243
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-06-14 to 2026-06-15 at inpatient hospital (POS 21). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Robert Nichols
- Member ID
- UHC-85627-10
- Date of birth
- 1989-09-18
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-425881
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5204
- Coverage period
- 2025-06-01 to present
- Deductible
- $689.91 of $1,000.0069%
- Out-of-pocket maximum
- $650.79 of $4,000.0016%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1807692383
- Network
- In network
- Rendering NPI
- 8602108648
- Location
- Mesa, AZ · TIN 56-5443846
- 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 | $176.00 | $96.80 | $96.80 | $0.00 | Paid |
| Totals | $176.00 | $96.80 | $96.80 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-858206
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-14 to 2026-06-18
- 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-020281 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-06-14: MEDICARE-ADV-A (MA), effective 2025-06-01. | |
| Timely filing | Pass | Received 27 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 (1807692383). | |
| 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 Associates2026-06-15 13:17
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-858206.pdf8 pages
Itemised statement totalling $176.00 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-2026-024480 | 2026-09-05 | Evergreen Orthopedic Specialists | $425.00 | Approved |
| CLM-2026-028228 | 2026-09-09 | Harbor Medical Group | $213.00 | 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.