CLM-2026-028803
Lakeside Regional Medical Center, Emergency Medicine. Service 2026-03-06 at emergency room (POS 23). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Dorothy Tucker
- Member ID
- UHC-02112-59
- Date of birth
- 2001-06-19
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-403809
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3941
- Coverage period
- 2024-05-01 to present
- Deductible
- $2.26 of $1,000.000%
- Out-of-pocket maximum
- $727.12 of $3,000.0024%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7132870750
- Network
- In network
- Rendering NPI
- 2102151364 (Heritage Community Hospital)
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $147.00 | $80.85 | — | — | Review |
| Totals | $147.00 | $80.85 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-151063
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024519 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-06: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-028802, billed by a different provider. Possible duplicate |
| 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 Center2026-03-06 14:20
Patient seen for chest pain, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-17 04:33
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-151063.pdf8 pages
Itemised statement totalling $147.00 across 1 line.
- Er reported_report_PA-151063.pdf4 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-028802, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028802 | 2026-03-06 | Heritage Community Hospital | $147.00 | Approved |
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
Different billing provider; separately payable.