CLM-2026-019353
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-21 at office (POS 11). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Walter Gonzales
- Member ID
- UHC-26891-85
- Date of birth
- 2003-04-13
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-410511
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0934
- Coverage period
- 2024-11-01 to present
- Deductible
- $198.42 of $500.0040%
- Out-of-pocket maximum
- $444.32 of $1,500.0030%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 6257361777
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- none / REF519391
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $201.00 | $124.62 | $40.00 | $84.62 | Paid |
| Totals | $201.00 | $124.62 | $40.00 | $84.62 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-271443
- 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-043737 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-21: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 19 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 Orthopedic Specialists (6175341661). | |
| 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 Orthopedic Specialists2026-08-21 11:21
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
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
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.