CLM-2026-028518
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-05-17 to 2026-05-19 at inpatient hospital (POS 21). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Bruce Adams
- Member ID
- UHC-74963-28
- Date of birth
- 1942-10-15
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-409138
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1458
- Coverage period
- 2021-07-01 to present
- Deductible
- $672.61 of $1,000.0067%
- Out-of-pocket maximum
- $990.69 of $2,000.0050%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5141407317
- Network
- In network
- Rendering NPI
- 7109799222
- Location
- Charlotte, NC · TIN 14-0698276
- Authorisation / referral
- none / REF398693
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 | $249.00 | $136.95 | — | — | Review |
| Totals | $249.00 | $136.95 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-651346
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-17 to 2026-05-21
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016420 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-17: NAVIGATE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 29 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 (5141407317). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Internal Medicine Associates2026-05-19 13:41
Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-17 05:21
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-651346.pdf8 pages
Itemised statement totalling $249.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021418 | 2026-01-21 | Lakeside Behavioral Health | $228.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.