CLM-2026-034457
Lakeside Regional Medical Center, Emergency Medicine. Service 2026-08-02 at emergency room (POS 23). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Michelle Walker
- Member ID
- UHC-17580-14
- Date of birth
- 2003-08-05
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-417287
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5013
- Coverage period
- 2024-05-01 to 2026-05-23
- Deductible
- $1,294.53 of $1,500.0086%
- Out-of-pocket maximum
- $1,552.63 of $4,500.0035%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 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 | $237.00 | $130.35 | — | — | DeniedCO27 |
| Totals | $237.00 | $130.35 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-496142
- 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-010036 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-02 is after coverage terminated on 2026-05-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 18 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 Center2026-08-02 18:46
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 01:03
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-20 17:32
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-496142.pdf4 pages
Itemised statement totalling $237.00 across 1 line.
- Er reported_report_PA-496142.pdf4 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-02 is after coverage terminated on 2026-05-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008631 | 2026-07-08 | Unity Reference Lab | $183.00 | Denied |
| CLM-2026-024521 | 2025-12-23 | Canyon Reference Lab | $31.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.