CLM-2026-032633
Lakeside Regional Medical Center, Emergency Medicine. Service 2026-04-07 at emergency room (POS 23). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Larry Barnes
- Member ID
- UHC-76599-05
- Date of birth
- 1958-04-09
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-406039
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3520
- Coverage period
- 2024-08-01 to present
- Deductible
- $190.80 of $1,500.0013%
- Out-of-pocket maximum
- $1,402.43 of $4,500.0031%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7132870750
- Network
- In network
- Rendering NPI
- 7132870750
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $255.00 | $140.25 | $140.25 | $0.00 | Paid |
| Totals | $255.00 | $140.25 | $140.25 | $0.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-977490
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- 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-024690 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-07: MEDICARE-ADV-A (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 26 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 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 Center2026-04-07 18:18
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-977490.pdf2 pages
Itemised statement totalling $255.00 across 1 line.
- Er reported_report_PA-977490.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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-2026-028586 | 2026-09-23 | Meadow Imaging Center | $2,651.00 | Needs review |
| CLM-2026-031641 | 2026-08-20 | Sunrise Internal Medicine Associates | $342.00 | Approved |
| CLM-2026-022942 | 2026-04-06 | Riverside GI Associates | $2,184.00 | Approved |
| CLM-2026-004825 | 2026-05-09 | Mesa Medical Group | $259.00 | 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.