CLM-2026-016134
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-04-19 at outpatient hospital (POS 22). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Betty Murray
- Member ID
- UHC-79482-59
- Date of birth
- 1986-04-20
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-429534
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3211
- Coverage period
- 2021-03-01 to present
- Deductible
- $187.21 of $500.0037%
- Out-of-pocket maximum
- $23.89 of $1,000.002%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 3461155681
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025018658 / 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 | $2,042.00 | $1,123.10 | $474.85 | $648.25 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $7,552.00 | $4,153.60 | $830.72 | $3,322.88 | Paid |
| Totals | $9,594.00 | $5,276.70 | $1,305.57 | $3,971.13 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-799923
- 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-016198 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-19: MEDICARE-ADV-B (MA), effective 2021-03-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025018658 on file for 73721, 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 Center2026-04-19 12:13
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2025018658_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-04-19 to 2026-07-18.
- Itemized billitemized_PA-799923.pdf9 pages
Itemised statement totalling $9594.00 across 2 lines.
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
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.