CLM-2026-004441
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-10 at office (POS 11). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Barbara Reed
- Member ID
- UHC-22780-50
- Date of birth
- 2006-12-15
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429294
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2023-11-01 to present
- Deductible
- $1,283.88 of $1,500.0086%
- Out-of-pocket maximum
- $791.22 of $4,500.0018%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 9385536609
- Location
- Nashville, TN · TIN 22-6450141
- 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 | $202.00 | $125.24 | — | — | DeniedCO18 |
| Totals | $202.00 | $125.24 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-245854
- 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-013462 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-10: CHOICE-PLUS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004440: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (9892398337). | |
| 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 Center2026-08-10 12:48
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-09-03 03:07
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-03 08:53
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-004440: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004440 | 2026-08-10 | Lakeside Bone and Joint Center | $202.00 | 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
Exact duplicate of an earlier submission.