CLM-2026-012614
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-25 at outpatient hospital (POS 22). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Ronald Espinoza
- Member ID
- UHC-88715-46
- Date of birth
- 1981-09-20
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407857
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0358
- Coverage period
- 2023-07-01 to present
- Deductible
- $576.84 of $1,000.0058%
- Out-of-pocket maximum
- $874.52 of $3,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 3684888381
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- PA2025109007 / 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 | $1,389.00 | $763.95 | $491.32 | $272.63 | Paid |
| Totals | $1,389.00 | $763.95 | $491.32 | $272.63 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-952521
- 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-002670 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: SELECT-EPO (EPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025109007 on file for 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 Specialists2026-02-25 15:54
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025109007_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-02-25 to 2026-05-26.
- Itemized billitemized_PA-952521.pdf8 pages
Itemised statement totalling $1389.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014280 | 2026-09-10 | Summit Reference Lab | $177.00 | Approved |
| CLM-2026-031561 | 2026-09-06 | Summit Cardiovascular Associates | $6,738.00 | Approved |
| CLM-2026-002272 | 2026-01-26 | Lakeside Skin Care Associates | $426.00 | 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.