CLM-2026-019708
Lakeside Medical Group, Internal Medicine. Service 2026-01-21 to 2026-01-22 at inpatient hospital (POS 21). Received 2026-02-28.
Member
Resolved through the identity graph
- Member
- Rachel Allen
- Member ID
- UHC-61641-27
- Date of birth
- 1990-08-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415901
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4249
- Coverage period
- 2023-09-01 to present
- Deductible
- $614.05 of $1,500.0041%
- Out-of-pocket maximum
- $801.97 of $3,000.0027%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 8689317682
- 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 | $252.00 | $138.60 | $138.60 | $0.00 | Paid |
| Totals | $252.00 | $138.60 | $138.60 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-124152
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-21 to 2026-01-24
- 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-008787 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-21: OPTIONS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 37 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 Group2026-01-22 10:06
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-124152.pdf8 pages
Itemised statement totalling $252.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002556 | 2026-09-05 | Sunrise Dermatology Clinic | $266.00 | Needs review |
| CLM-2026-002555 | 2026-09-05 | Sunrise Dermatology Clinic | $266.00 | 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.