CLM-2026-019072
Lakeside Regional Medical Center, Emergency Medicine. Service 2026-05-29 at emergency room (POS 23). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Walter Wang
- Member ID
- UHC-97777-83
- Date of birth
- 1947-09-13
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-401764
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1011
- Coverage period
- 2024-12-01 to present
- Deductible
- $590.23 of $1,000.0059%
- Out-of-pocket maximum
- $963.79 of $4,000.0024%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 19 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 / 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,144.00 | $1,729.20 | $250.00 | $1,479.20 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $150.00 | $82.50 | $0.00 | $82.50 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,018.00 | $559.90 | $0.00 | $559.90 | Paid |
| Totals | $4,312.00 | $2,371.60 | $250.00 | $2,121.60 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-250969
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028383 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-29: MEDICARE-ADV-B (MA), effective 2024-12-01. | |
| 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 Center2026-05-29 14:02
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-250969.pdf6 pages
Itemised statement totalling $4312.00 across 3 lines.
- Er reported_report_PA-250969.pdf5 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002352 | 2026-07-17 | Cornerstone Cardiovascular Associates | $1,087.00 | 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.