CLM-2026-009435
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Ruth Owens
- Member ID
- UHC-38282-21
- Date of birth
- 1988-01-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409878
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4372
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,120.25 of $2,500.0045%
- Out-of-pocket maximum
- $2,558.08 of $7,500.0034%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 7184959139
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- none / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,356.00 | $1,295.80 | — | — | DeniedCO197 |
| Totals | $2,356.00 | $1,295.80 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-263150
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008515 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-12: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-005415, billed by a different provider. Possible duplicate |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-07-12 14:49
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-08-04 04:29
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-263150.pdf2 pages
Itemised statement totalling $2356.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-005415, billed by a different provider. Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005415 | 2026-07-12 | Unity Bone and Joint Center | $1,294.00 | Approved |
| CLM-2026-016688 | 2026-01-11 | Valley Primary Care Associates | $13.00 | 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
Precertification required and absent.