CLM-2026-016903
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2025-10-14 at outpatient hospital (POS 22). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Omar Stevens
- Member ID
- UHC-20389-49
- Date of birth
- 1970-10-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419964
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5670
- Coverage period
- 2022-04-01 to present
- Deductible
- $474.99 of $2,500.0019%
- Out-of-pocket maximum
- $327.16 of $7,500.004%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 8983950634
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2026594641 / REF367419
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 | $8,657.00 | $4,761.35 | — | — | DeniedCO29 |
| Totals | $8,657.00 | $4,761.35 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-550917
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014406 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-14: NAVIGATE-HMO (HMO), effective 2022-04-01. | |
| Timely filing | Fail | CO29 | Received 128 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026594641 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 Center2025-10-14 12:19
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-19 03:12
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026594641_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-10-14 to 2026-01-12.
- Itemized billitemized_PA-550917.pdf6 pages
Itemised statement totalling $8657.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 128 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031016 | 2026-07-27 | Northgate Internal Medicine Associates | $397.00 | 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
Received after the timely-filing limit.