CLM-2026-000505
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-12 at outpatient hospital (POS 22). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Betty Fox
- Member ID
- UHC-83505-18
- Date of birth
- 1967-09-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422854
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9390
- Coverage period
- 2021-12-01 to 2026-03-22
- Deductible
- $767.57 of $1,000.0077%
- Out-of-pocket maximum
- $439.97 of $4,000.0011%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 6366244104
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025776005 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,804.00 | $992.20 | — | — | DeniedCO27 |
| Totals | $1,804.00 | $992.20 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-840822
- 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-042727 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-12 is after coverage terminated on 2026-03-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025776005 on file for 73721. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (4688502655). | |
| 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 Bone and Joint Center2026-08-12 16:14
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-08-27 00:14
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-27 08:23
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025776005_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-08-12 to 2026-11-10.
- Itemized billitemized_PA-840822.pdf9 pages
Itemised statement totalling $1804.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-12 is after coverage terminated on 2026-03-22.
Other claims for this member
Same resolved identity
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.