Professional claim · CMS-1500 · EDI 837P
CLM-2026-013346
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-09 at office (POS 11). Received 2026-01-20.
Billed
$466.00
2 lines
Allowed
$288.92
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Priya Barnes
- Member ID
- UHC-69445-73
- Date of birth
- 2006-09-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406913
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5082
- Coverage period
- 2025-04-01 to 2026-03-24
- Deductible
- $1,153.94 of $1,500.0077%
- Out-of-pocket maximum
- $786.63 of $6,000.0013%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 9285817380
- Location
- Phoenix, AZ · TIN 50-3046245
- 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 | $264.00 | $163.68 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $202.00 | $125.24 | — | — | PendedIDQ |
| Totals | $466.00 | $288.92 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M17.12 Unilateral primary osteoarthritis, left knee
Claim header
- Patient account
- PA-136464
- 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 | Fail | IDQ | Member record is in open steward case CASE-000258; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-01-09: OPTIONS-PPO (PPO), effective 2025-04-01, terms 2026-03-24. | |
| Timely filing | Pass | Received 11 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 Bone and Joint Center (2952838284). | |
| 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. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-01-09 18:18
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000258; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013347 | 2026-01-09 | Lakeside Bone and Joint Center | $466.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.