CLM-2026-002045
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-20 at outpatient hospital (POS 22). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Jimmy Watkins
- Member ID
- UHC-77031-08
- Date of birth
- 1957-08-25
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-410999
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4904
- Coverage period
- 2023-09-01 to present
- Deductible
- $835.08 of $1,500.0056%
- Out-of-pocket maximum
- $550.07 of $4,500.0012%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 4015795741
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025826362 / REF654819
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 | $1,792.00 | $985.60 | $761.12 | $224.48 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,045.00 | $5,524.75 | $1,657.43 | $3,867.32 | Paid |
| Totals | $11,837.00 | $6,510.35 | $2,418.55 | $4,091.80 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-729313
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002822 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-20: NAVIGATE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025826362 on file for 73721, 29881. | |
| 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 Center2026-05-20 10:26
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025826362_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-20 to 2026-08-18.
- Itemized billitemized_PA-729313.pdf2 pages
Itemised statement totalling $11837.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027225 | 2026-01-17 | Cornerstone Cardiovascular Associates | $6,356.00 | Approved |
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.