CLM-2026-009607
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-10 at outpatient hospital (POS 22). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Philip Larson
- Member ID
- UHC-32280-28
- Date of birth
- 1953-11-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418367
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8145
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,309.39 of $1,500.0087%
- Out-of-pocket maximum
- $1,150.50 of $3,000.0038%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 1636151320
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- PA2025235984 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,850.00 | $4,867.50 | $658.30 | $4,209.20 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 2 | $1,648.00 | $906.40 | $90.64 | $815.76 | Paid |
| Totals | $10,498.00 | $5,773.90 | $748.94 | $5,024.96 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-648642
- 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-015880 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: CHOICE-PLUS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025235984 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Lakeside Orthopedic Specialists (6175341661). | |
| 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 Orthopedic Specialists2026-03-10 13:48
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025235984_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-10 to 2026-06-08.
- Itemized billitemized_PA-648642.pdf4 pages
Itemised statement totalling $10498.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.