Professional claim · CMS-1500 · EDI 837P
CLM-2026-009744
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-26 at office (POS 11). Received 2026-03-22.
Approved
Billed
$255.00
1 line
Allowed
$158.10
contract rate applied
Plan pays
$98.10
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Patricia Gomez
- Member ID
- UHC-71807-52
- Date of birth
- 1940-10-24
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-408750
- Relationship
- Child, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8072
- Coverage period
- 2021-04-01 to present
- Deductible
- $227.10 of $500.0045%
- Out-of-pocket maximum
- $609.21 of $1,500.0041%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 3680518164
- Location
- San Diego, CA · TIN 92-6249364
- 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 | $255.00 | $158.10 | $60.00 | $98.10 | Paid |
| Totals | $255.00 | $158.10 | $60.00 | $98.10 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-798542
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005382 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-26: SELECT-EPO (EPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 24 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 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Orthopedic Specialists2026-02-26 16:06
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$255.00
Plan discount
$96.90
contracted rate
Plan paid
$98.10
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000220 | 2026-05-01 | Summit Regional Medical Center | $1,203.00 | Denied |
| CLM-2026-000219 | 2026-05-01 | Summit Regional Medical Center | $1,203.00 | Approved |
| CLM-2026-019769 | 2026-01-10 | Harbor Digestive Health Center | $3,507.00 | Denied |
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.