Claims workbench/CLM-2026-023471

Institutional claim · UB-04 · EDI 837I

CLM-2026-023471

Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-26 to 2026-01-28 at inpatient hospital (POS 21). Received 2026-03-09.

Needs reviewReplacement of CLM-2026-023470

Billed

$46,951.00

1 line

Allowed

$25,823.05

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

REPL, HIGH

Decided by

Nobody yet

open

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 Center
Orthopedic 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	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal

Claim header

Patient account: PA-831434
Frequency code: 7 (replacement)
Accident: No
DRG: 470
Admit / discharge: 2026-01-26 to 2026-01-28
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 2 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 40 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-023470; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
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

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Bone and Joint Center2026-01-28 11:20
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-03-09 05:36
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

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-831434.pdf9 pages
Itemised statement totalling $46951.00 across 1 line.
Corrected claimcorrected_CLM-2026-023470.pdf1 page
Provider cover letter requesting replacement of CLM-2026-023470.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-023470; the original must be voided when this adjudicates. High-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-2026-023470	2026-01-26	Lakeside Bone and Joint Center	$46,951.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity