CLM-2026-006970
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2025-11-22 at office (POS 11). Received 2026-05-10.
Member
Resolved through the identity graph
- Member
- Frank Ramirez
- Member ID
- UHC-29023-35
- Date of birth
- 1947-10-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402764
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0471
- Coverage period
- 2021-01-01 to present
- Deductible
- $384.16 of $500.0077%
- Out-of-pocket maximum
- $62.33 of $1,000.006%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 1167688724
- Location
- Nashville, TN · TIN 22-6450141
- Authorisation / referral
- none / REF661203
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $179.00 | $110.98 | — | — | DeniedCO29 |
| 2 | 20610 | Joint injection, major joint | — | 1 | 1 | $214.00 | $132.68 | — | — | DeniedCO29 |
| Totals | $393.00 | $243.66 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-169026
- 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-003482 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-22: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Fail | CO29 | Received 169 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 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 Center2025-11-22 16:09
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-05-10 06:05
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-10 14:31
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 169 days after the last date of service (limit 90).
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
Received after the timely-filing limit.