CLM-2026-032478
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-09-30 to 2026-10-02 at inpatient hospital (POS 21). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Ralph Garza
- Member ID
- UHC-69417-14
- Date of birth
- 1947-08-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403947
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2826
- Coverage period
- 2025-05-01 to present
- Deductible
- $217.41 of $3,500.006%
- Out-of-pocket maximum
- $345.57 of $14,000.002%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 2010489146
- Location
- Los Angeles, CA · TIN 18-5876521
- Authorisation / referral
- none / REF429958
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 | $203.00 | $111.65 | $111.65 | $0.00 | Paid |
| Totals | $203.00 | $111.65 | $111.65 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-839520
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-30 to 2026-10-04
- 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-039721 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-30: CORE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Pass | Received 4 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 (6644545769). | |
| 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 Internal Medicine Associates2026-10-02 15:53
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-839520.pdf9 pages
Itemised statement totalling $203.00 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-2026-032479 | 2026-09-30 | Lakeside Internal Medicine Associates | $203.00 | Needs review |
| CLM-2026-024415 | 2026-07-04 | Northgate Orthopedic Specialists | $299.00 | 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.