CLM-2026-000766
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-15 to 2026-07-18 at inpatient hospital (POS 21). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Larry Freeman
- Member ID
- UHC-74769-25
- Date of birth
- 1973-10-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413500
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2023-01-01 to 2026-01-13
- Deductible
- $886.59 of $1,000.0089%
- Out-of-pocket maximum
- $262.86 of $2,000.0013%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 4557847223
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2025295213 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $38,934.00 | $21,413.70 | — | — | DeniedCO27 |
| Totals | $38,934.00 | $21,413.70 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-897596
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-07-15 to 2026-07-16
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004317 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-15 is after coverage terminated on 2026-01-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025295213 on file for 27447. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (2952838284). | |
| 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 | Review | HIGH | Billed $38,934.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-07-18 09:23
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-21 04:12
Attachments
Documents received with the claim
- Prior auth letterPA2025295213_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-07-15 to 2026-10-13.
- Itemized billitemized_PA-897596.pdf7 pages
Itemised statement totalling $38934.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-15 is after coverage terminated on 2026-01-13. High-dollar review: Billed $38,934.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
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.