Claims workbench/CLM-2026-011193
Institutional claim · UB-04 · EDI 837I

CLM-2026-011193

Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-05 to 2025-12-07 at inpatient hospital (POS 21). Received 2026-01-07.

Needs review
Billed
$45,350.00
1 line
Allowed
$24,942.50
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Review
HIGH
Decided by
Nobody yet
open

Member

Resolved through the identity graph

Member
Lisa Graham
Member ID
UHC-27955-94
Date of birth
1951-12-26
Identity
Verified4 records, confidence 0.93
Claim record
CLMCLM-432229
Relationship
Spouse, Tampa, FL

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-0788
Coverage period
2023-12-01 to present
Deductible
$1,663.40 of $2,500.0067%
Out-of-pocket maximum
$2,032.42 of $7,500.0027%
Copays
office $20.00, specialist $50.00, emergency $150.00
Physical therapy visits
1 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI
6175341661
Network
In network
Rendering NPI
7491694239
Location
San Diego, CA · TIN 92-6249364
Authorisation / referral
PA2026712700 / REF405508

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
127447
rev 0360
Total knee arthroplasty—11$45,350.00$24,942.50——Review
Totals$45,350.00$24,942.50——
Diagnoses (ICD-10-CM)
  • 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-176283
Frequency code
1 (original)
Accident
No
DRG
470
Admit / discharge
2025-12-05 to 2025-12-06
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-002103 (verified, link confidence 0.93).
EligibilityPassActive on 2025-12-05: CORE-HMO (HMO), effective 2023-12-01.
Timely filingPassReceived 31 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026712700 on file for 27447.
Provider networkPassIn-network provider Lakeside Orthopedic Specialists (6175341661).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewReviewHIGHBilled $45,350.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Billed amount above auto-pay ceiling
Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Lakeside Orthopedic Specialists2025-12-07 15:50

    Patient seen for unilateral primary osteoarthritis, right knee. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.

  • SystemSystem: Claims system2026-01-07 01:02

    Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.

Attachments

Documents received with the claim

  • Prior auth letterPA2026712700_approval.pdf2 pages

    Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-05 to 2026-03-05.

  • Itemized billitemized_PA-176283.pdf3 pages

    Itemised statement totalling $45350.00 across 1 line.

  • Medical recordrecords_PA-176283.pdf6 pages

    Discharge summary and operative report.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineReview2026-10-21 13:43
    High-dollar review: Billed $45,350.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
  2. AI recommendationApproved2026-10-21 14:15
    The claim for a total knee arthroplasty is supported by the member's active coverage, in-network provider status, and prior authorization. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off. The clinical note and discharge summary confirm the medical necessity and completion of the procedure. The claim is approved pending human review due to the high-dollar amount.
  3. AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · ce54e958

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0135882026-04-09Evergreen Diagnostic Imaging$3,288.00Needs review

AI recommendation

apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode

Approvedconfidence 0.95Needs examiner sign-off Validated

The claim for a total knee arthroplasty is supported by the member's active coverage, in-network provider status, and prior authorization. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off. The clinical note and discharge summary confirm the medical necessity and completion of the procedure. The claim is approved pending human review due to the high-dollar amount.

Evidence cited: [C][DX][L1][PRV][IDN][COV][R-identity][R-eligibility][R-timely_filing][R-duplicate][R-prior_auth][R-network][R-clinical_edit][R-ncci][R-benefit_limit][R-completeness][R-high_dollar][N1][N2][A1][A2][A3]
Latency
2,911 ms
Tokens
1,418 in / 230 out
Cost
$0.0019
Input hash ef85f883587d8210… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record it.
Outcome
449 characters
ExaminerR. Patel (Claims Examiner II)
Will apply: approve

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

ApprovedHIGHscenario: High dollar

Above auto-pay ceiling; payable once an examiner signs off.

Review queueMember identity