CLM-2026-022542
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Priya Smith
- Member ID
- UHC-16634-84
- Date of birth
- 1955-02-13
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-425485
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6981
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,567.82 of $2,500.0063%
- Out-of-pocket maximum
- $2,123.03 of $7,500.0028%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 7357622332
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2026518329 / 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 | $1,360.00 | $748.00 | $748.00 | $0.00 | Paid |
| Totals | $1,360.00 | $748.00 | $748.00 | $0.00 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-440941
- 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-010050 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-08: CHOICE-PLUS-PPO (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026518329 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 Center2026-01-08 09:22
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026518329_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-440941.pdf5 pages
Itemised statement totalling $1360.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 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.