CLM-2026-023860
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-03-22 at outpatient hospital (POS 22). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Frak Green
- Member ID
- UHC-08081-74
- Date of birth
- 1974-04-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404552
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4584
- Coverage period
- 2024-11-01 to present
- Deductible
- $727.96 of $1,500.0049%
- Out-of-pocket maximum
- $1,851.29 of $4,500.0041%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 1257481683
- Location
- Nashville, TN · TIN 22-6450141
- Authorisation / referral
- PA2025337401 / 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 | $6,165.00 | $3,390.75 | $1,557.65 | $1,833.10 | Paid |
| Totals | $6,165.00 | $3,390.75 | $1,557.65 | $1,833.10 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-835873
- 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-024491 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-22: CHOICE-PLUS-PPO (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025337401 on file for 29881. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-03-22 17:30
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025337401_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-22 to 2026-06-20.
- Itemized billitemized_PA-835873.pdf3 pages
Itemised statement totalling $6165.00 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.