CLM-2026-020258
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-01 to 2025-12-05 at inpatient hospital (POS 21). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Larry Perez
- Member ID
- UHC-26253-85
- Date of birth
- 1982-05-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416378
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1740
- Coverage period
- 2024-04-01 to present
- Deductible
- $276.03 of $1,500.0018%
- Out-of-pocket maximum
- $2.35 of $3,000.000%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 5368365388
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025011518 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $48,120.00 | $26,466.00 | — | — | Review |
| Totals | $48,120.00 | $26,466.00 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-784457
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-01 to 2025-12-02
- 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-001932 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-01: OPTIONS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025011518 on file for 27447. | |
| 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 | Review | HIGH | Billed $48,120.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2025-12-05 12:43
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-07 04:46
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2025011518_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-01 to 2026-03-01.
- Itemized billitemized_PA-784457.pdf9 pages
Itemised statement totalling $48120.00 across 1 line.
- Medical recordrecords_PA-784457.pdf21 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $48,120.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-21 14:15The claim for total knee arthroplasty is supported by the member's active coverage [COV], in-network provider status [PRV], and prior authorisation [A1]. The clinical note [N1] and medical record [A3] confirm the medical necessity and completion of the procedure. Although the billed amount exceeds the auto-adjudication ceiling [R-high_dollar], the documentation is complete and the service is covered. Examiner sign-off is required due to the high-dollar amount [N2].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · aa428923
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034372 | 2026-02-28 | Sunrise Internal Medicine Associates | $313.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for total knee arthroplasty is supported by the member's active coverage [COV], in-network provider status [PRV], and prior authorisation [A1]. The clinical note [N1] and medical record [A3] confirm the medical necessity and completion of the procedure. Although the billed amount exceeds the auto-adjudication ceiling [R-high_dollar], the documentation is complete and the service is covered. Examiner sign-off is required due to the high-dollar amount [N2].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Above auto-pay ceiling; payable once an examiner signs off.