CLM-2026-000348
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-09 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Alice Bryant
- Member ID
- UHC-87888-26
- Date of birth
- 1967-08-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417493
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8488
- Coverage period
- 2024-05-01 to 2026-01-27
- Deductible
- $438.67 of $3,500.0013%
- Out-of-pocket maximum
- $1,162.09 of $7,000.0017%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 5001257695
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $306.00 | $189.72 | — | — | DeniedCO27 |
| Totals | $306.00 | $189.72 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-524154
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002662 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-09 is after coverage terminated on 2026-01-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 Orthopedic Specialists (6175341661). | |
| 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 Orthopedic Specialists2026-03-09 09:09
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-20 02:08
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-20 14:01
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-09 is after coverage terminated on 2026-01-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002428 | 2026-01-19 | Canyon Cardiovascular Associates | $235.00 | 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.