CLM-2026-015393
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Raymond Collins
- Member ID
- UHC-19511-99
- Date of birth
- 1938-06-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-423511
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9535
- Coverage period
- 2021-05-01 to present
- Deductible
- $2,196.57 of $3,500.0063%
- Out-of-pocket maximum
- $1,126.21 of $7,000.0016%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 6207226252
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025276823 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $6,749.00 | $3,711.95 | $1,785.13 | $1,926.82 | Paid |
| Totals | $6,749.00 | $3,711.95 | $1,785.13 | $1,926.82 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-365265
- 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-037280 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-21: MEDICARE-ADV-B (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025276823 on file for 29881. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (4688502655). | |
| 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 Center2026-08-21 10:55
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025276823_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-21 to 2026-11-19.
- Itemized billitemized_PA-365265.pdf4 pages
Itemised statement totalling $6749.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020006 | 2026-06-11 | Sunrise Physical Therapy | $216.00 | 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.