CLM-2026-020831
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-06-10 at outpatient hospital (POS 22). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Valentina Moore
- Member ID
- UHC-89782-29
- Date of birth
- 1979-09-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409225
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7365
- Coverage period
- 2023-11-01 to present
- Deductible
- $735.70 of $1,500.0049%
- Out-of-pocket maximum
- $1,896.00 of $6,000.0032%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 7738920579
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2025828927 / 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 | $1,431.00 | $787.05 | $771.13 | $15.92 | Paid |
| Totals | $1,431.00 | $787.05 | $771.13 | $15.92 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-652007
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032638 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-10: - (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025828927 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 Center2026-06-10 18:50
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025828927_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-06-10 to 2026-09-08.
- Itemized billitemized_PA-652007.pdf9 pages
Itemised statement totalling $1431.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020832 | 2026-06-10 | Lakeside Bone and Joint Center | $1,431.00 | Denied |
| CLM-2026-004664 | 2026-05-16 | Lakeside Medical Group | $3,057.00 | Needs review |
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.