CLM-2026-019394
Lakeside Regional Medical Center, Emergency Medicine. Service 2025-12-06 at emergency room (POS 23). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Susan Burke
- Member ID
- UHC-70463-11
- Date of birth
- 1985-02-25
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410856
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7184
- Coverage period
- 2021-07-01 to present
- Deductible
- $426.43 of $500.0085%
- Out-of-pocket maximum
- $64.29 of $1,500.004%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,504.00 | $827.20 | $150.00 | $677.20 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $1,035.00 | $569.25 | $0.00 | $569.25 | Paid |
| Totals | $2,539.00 | $1,396.45 | $150.00 | $1,246.45 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-800444
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-004512 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-06: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Pass | Received 40 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 Center2025-12-06 12:23
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-800444.pdf8 pages
Itemised statement totalling $2539.00 across 2 lines.
- Er reported_report_PA-800444.pdf5 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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-2026-021323 | 2026-04-07 | Cornerstone Family Practice | $339.00 | Approved |
| CLM-2026-027620 | 2026-04-02 | Canyon Cardiovascular Associates | $7,058.00 | Approved |
| CLM-2026-030042 | 2025-12-15 | Unity Diagnostic Imaging | $330.00 | 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.