Claims workbench/CLM-2026-020583

Institutional claim · UB-04 · EDI 837I

CLM-2026-020583

Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-24 to 2026-09-25 at inpatient hospital (POS 21). Received 2026-10-13.

Denied

Billed

$48,569.00

1 line

Allowed

$26,712.95

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Tyler Yang
Member ID: UHC-30040-50
Date of birth: 1969-10-20
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-432639
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-0765
Coverage period: 2024-04-01 to present
Deductible: $243.42 of $500.0049%
Out-of-pocket maximum: $573.78 of $2,000.0029%
Copays: office $25.00, specialist $40.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 6175341661
Network: In network
Rendering NPI: 6315257538
Location: San Diego, CA · TIN 92-6249364
Authorisation / referral: none / REF368334

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	$48,569.00	$26,712.95	—	—	DeniedCO197
Totals						$48,569.00	$26,712.95	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter

Claim header

Patient account: PA-956847
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-09-24 to 2026-09-28
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-016515 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-24: NAVIGATE-HMO (HMO), effective 2024-04-01.
Timely filing	Pass		Received 18 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	27447 require precertification; no authorisation number on the claim. Precertification or authorization absent
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	Review	HIGH	Billed $48,569.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Orthopedic Specialists2026-09-25 09:43
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-10-13 04:21
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-13 11:11
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-956847.pdf6 pages
Itemised statement totalling $48569.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $48,569.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity