CLM-2026-021112
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-20 at office (POS 11). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Harold Murray
- Member ID
- UHC-51489-92
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415577
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-7015
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,150.36 of $1,500.0077%
- Out-of-pocket maximum
- $844.07 of $6,000.0014%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 4895428298
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- none / none
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 | — | 1 | 1 | $318.00 | $197.16 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $188.00 | $116.56 | — | — | PendedIDQ |
| Totals | $506.00 | $313.72 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-565103
- 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 | Fail | IDQ | Member record is in open steward case CASE-001275; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-02-20: UNKNOWN (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 22 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 | Review | CO16 | Documentation incomplete: “Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dic”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Orthopedic Specialists2026-02-20 10:07
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-14 04:52
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001275; payment withheld until the identity is confirmed. Completeness: Documentation incomplete: “Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dic”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Development letter outstanding.