CLM-2026-025076
Lakeside Medical Group, Internal Medicine. Service 2026-07-24 to 2026-07-28 at inpatient hospital (POS 21). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Jason Grant
- Member ID
- UHC-51451-91
- Date of birth
- 1946-01-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-407779
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9830
- Coverage period
- 2024-04-01 to 2026-08-09
- Deductible
- $909.91 of $2,500.0036%
- Out-of-pocket maximum
- $2,754.09 of $7,500.0037%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 2143231852
- Network
- In network
- Rendering NPI
- 2586494124
- Location
- Houston, TX · TIN 29-4552150
- 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 | $219.00 | $120.45 | $120.45 | $0.00 | Paid |
| Totals | $219.00 | $120.45 | $120.45 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-717568
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-24 to 2026-07-28
- 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-020243 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-24: MEDICARE-ADV-B (MA), effective 2024-04-01, terms 2026-08-09. | |
| Timely filing | Pass | Received 23 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 (2143231852). | |
| 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 Group2026-07-28 10:13
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-717568.pdf5 pages
Itemised statement totalling $219.00 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-2026-024641 | 2026-08-21 | Canyon Reference Lab | $73.00 | Denied |
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.