CLM-2026-023470
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-26 to 2026-01-28 at inpatient hospital (POS 21). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Hiroshi Montgomery
- Member ID
- UHC-28875-07
- Date of birth
- 1976-04-17
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-420953
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6813
- Coverage period
- 2023-08-01 to present
- Deductible
- $51.28 of $500.0010%
- Out-of-pocket maximum
- $897.14 of $2,000.0045%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 7735728686
- Location
- Nashville, TN · TIN 22-6450141
- Authorisation / referral
- PA2026134520 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $46,951.00 | $25,823.05 | — | — | Review |
| Totals | $46,951.00 | $25,823.05 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-393225
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-01-26 to 2026-01-28
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017120 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-26: NULL (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026134520 on file for 27447. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (9892398337). | |
| 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 $46,951.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-01-28 14:53
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026134520_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-01-26 to 2026-04-26.
- Itemized billitemized_PA-393225.pdf2 pages
Itemised statement totalling $46951.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $46,951.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004021 | 2026-08-13 | Meadow Primary Care Associates | $414.00 | Approved |
| CLM-2026-024820 | 2026-05-14 | Meadow Clinical Laboratories | $42.00 | Approved |
| CLM-2026-012911 | 2026-04-07 | Lakeside Imaging Center | $323.00 | Approved |
| CLM-2026-023471 | 2026-01-26 | Lakeside Bone and Joint Center | $46,951.00 | Needs review |
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
Clean claim, priced at contract rate.