CLM-2026-018098
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-09-19 at office (POS 11). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Patrick Padilla
- Member ID
- UHC-49823-74
- Date of birth
- 1968-02-15
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-431877
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4059
- Coverage period
- 2023-12-01 to 2026-02-16
- Deductible
- $557.38 of $2,500.0022%
- Out-of-pocket maximum
- $435.90 of $5,000.009%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 2733666962
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- none / REF790942
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | 59 | 1 | 1 | $220.00 | $136.40 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $228.00 | $141.36 | — | — | DeniedCO27 |
| Totals | $448.00 | $277.76 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-563707
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020833 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-19 is after coverage terminated on 2026-02-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (2952838284). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2026-09-19 14:21
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-23 05:52
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-09-19 is after coverage terminated on 2026-02-16. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005112 | 2026-08-14 | Meadow Primary Care Associates | $146.00 | 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.