CLM-2026-012968
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-09 at office (POS 11). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Karen Padilla
- Member ID
- UHC-05442-22
- Date of birth
- 1998-05-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419516
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9339
- Coverage period
- 2022-09-01 to 2026-04-12
- Deductible
- $171.54 of $500.0034%
- Out-of-pocket maximum
- $950.97 of $2,000.0048%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 7362266414
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- none / REF168967
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | — | — | DeniedCO27 |
| Totals | $192.00 | $119.04 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-529115
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008173 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-09 is after coverage terminated on 2026-04-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Orthopedic Specialists2026-09-09 16:56
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-09-23 05:52
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-23 09:56
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-09 is after coverage terminated on 2026-04-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006579 | 2026-05-20 | Evergreen Primary Care Associates | $2,010.00 | Denied |
| CLM-2026-009397 | 2026-01-07 | Evergreen Clinical Laboratories | $49.00 | Denied |
| CLM-2026-009396 | 2026-01-07 | Evergreen Clinical Laboratories | $49.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.