CLM-2026-033638
Lakeside Internal Medicine Associates, Internal Medicine. Service 2025-12-22 to 2025-12-23 at inpatient hospital (POS 21). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Ralph Jackson
- Member ID
- UHC-30546-95
- Date of birth
- 1970-11-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423778
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group UNKNOWN
- Coverage period
- 2024-08-01 to present
- Deductible
- $1,270.46 of $1,500.0085%
- Out-of-pocket maximum
- $987.73 of $3,000.0033%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1807692383
- Network
- In network
- Rendering NPI
- 3212257349
- Location
- Mesa, AZ · TIN 56-5443846
- 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 | $198.00 | $108.90 | $108.90 | $0.00 | Paid |
| Totals | $198.00 | $108.90 | $108.90 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-491443
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-22 to 2025-12-23
- 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-008455 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-22: NULL (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 36 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 (1807692383). | |
| 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 Associates2025-12-23 14:49
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-491443.pdf5 pages
Itemised statement totalling $198.00 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
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.