CLM-2026-023074
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-03-18 at outpatient hospital (POS 22). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Rebecca Jacobs
- Member ID
- UHC-14819-53
- Date of birth
- 1971-06-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-430781
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6818
- Coverage period
- 2023-05-01 to present
- Deductible
- $605.34 of $1,500.0040%
- Out-of-pocket maximum
- $1,230.15 of $3,000.0041%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 5453694759
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2025240116 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $7,369.00 | $4,052.95 | — | — | Review |
| Totals | $7,369.00 | $4,052.95 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-186338
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021607 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-18: MEDICARE-ADV-A (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-023073, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | Authorisation PA2025240116 on file for 29881. | |
| 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 Center2026-03-18 13:09
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-11 04:54
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-11 17:43
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025240116_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-18 to 2026-06-16.
- Itemized billitemized_PA-186338.pdf9 pages
Itemised statement totalling $7369.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-023073, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025576 | 2026-05-03 | Pinecrest Primary Care Associates | $185.00 | Approved |
| CLM-2026-017115 | 2026-02-28 | Lakeside Internal Medicine Associates | $297.00 | Approved |
| CLM-2026-023073 | 2026-03-18 | Cornerstone Orthopedic Specialists | $7,369.00 | Approved |
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
Different billing provider; separately payable.