Professional claim · CMS-1500 · EDI 837P
CLM-2026-008948
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-06-18 at office (POS 11). Received 2026-08-02.
Approved
Billed
$471.00
2 lines
Allowed
$292.02
contract rate applied
Plan pays
$217.02
approved
Member owes
$75.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Kyle Salazar
- Member ID
- UHC-29672-58
- Date of birth
- 1941-01-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427491
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2626
- Coverage period
- 2024-11-01 to present
- Deductible
- $2,667.49 of $3,500.0076%
- Out-of-pocket maximum
- $927.11 of $7,000.0013%
- Copays
- office $25.00, specialist $75.00, 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
- 4688502655
- Network
- In network
- Rendering NPI
- 3289121519
- Location
- Austin, TX · TIN 36-5200643
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $186.00 | $115.32 | $75.00 | $40.32 | Paid |
| 2 | 20610 | Joint injection, major joint | — | 1 | 1 | $285.00 | $176.70 | $0.00 | $176.70 | Paid |
| Totals | $471.00 | $292.02 | $75.00 | $217.02 | ||||||
Diagnoses (ICD-10-CM)
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-774825
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001595 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-18: MEDICARE-ADV-A (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| 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 (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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-06-18 12:12
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$471.00
Plan discount
$178.98
contracted rate
Plan paid
$217.02
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020164 | 2026-07-24 | Cornerstone Internal Medicine Associates | $193.00 | Approved |
| CLM-2026-010400 | 2026-06-27 | Lakeside Endocrine Associates | $327.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.