CLM-2026-017761
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-04-26 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Nancy Castillo
- Member ID
- UHC-50056-60
- Date of birth
- 1967-03-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411408
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0604
- Coverage period
- 2023-01-01 to 2026-01-12
- Deductible
- $407.15 of $1,500.0027%
- Out-of-pocket maximum
- $1,667.82 of $4,500.0037%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 3582404372
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2025144114 / 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 | $1,151.00 | $633.05 | — | — | DeniedCO27 |
| Totals | $1,151.00 | $633.05 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-222821
- 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 | Pass | Attached to MBR-016654 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-26 is after coverage terminated on 2026-01-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025144114 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 Center2026-04-26 15:12
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-09 02:08
Attachments
Documents received with the claim
- Prior auth letterPA2025144114_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-04-26 to 2026-07-25.
- Itemized billitemized_PA-222821.pdf8 pages
Itemised statement totalling $1151.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-26 is after coverage terminated on 2026-01-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015817 | 2026-03-14 | Desert Internal Medicine Associates | $228.00 | Denied |
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
Service after coverage termination.