CLM-2026-014006
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Ann Holmes
- Member ID
- UHC-62292-14
- Date of birth
- 1939-01-21
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425186
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0883
- Coverage period
- 2023-09-01 to present
- Deductible
- $1,824.22 of $2,500.0073%
- Out-of-pocket maximum
- $1,239.87 of $7,500.0017%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 9251906480
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2025112985 / 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 | $1,840.00 | $1,012.00 | $776.65 | $235.35 | Paid |
| Totals | $1,840.00 | $1,012.00 | $776.65 | $235.35 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-517962
- 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-023245 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-06: SELECT-EPO (EPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025112985 on file for 73721. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-05-06 15:45
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025112985_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-06 to 2026-08-04.
- Itemized billitemized_PA-517962.pdf2 pages
Itemised statement totalling $1840.00 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
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.