CLM-2026-009801
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-09 at outpatient hospital (POS 22). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Mariana Gordon
- Member ID
- UHC-48651-30
- Date of birth
- 2002-12-27
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-430304
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1699
- Coverage period
- 2022-01-01 to present
- Deductible
- $3,086.68 of $3,500.0088%
- Out-of-pocket maximum
- $4,850.46 of $10,500.0046%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 2253180857
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025957767 / 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 | $7,319.00 | $4,025.45 | $1,135.75 | $2,889.70 | Paid |
| Totals | $7,319.00 | $4,025.45 | $1,135.75 | $2,889.70 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-895678
- 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-007032 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-09: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025957767 on file for 29881. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2025-12-09 13:52
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025957767_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-12-09 to 2026-03-09.
- Itemized billitemized_PA-895678.pdf4 pages
Itemised statement totalling $7319.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024254 | 2026-04-24 | Summit Endocrine Associates | $455.00 | Approved |
| CLM-2026-011912 | 2026-01-23 | Evergreen Family Practice | $588.00 | Approved |
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.