CLM-2026-024020
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-11 at outpatient hospital (POS 22). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Alexis Ramirez
- Member ID
- UHC-68210-89
- Date of birth
- 1964-04-18
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-405143
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4541
- Coverage period
- 2023-12-01 to present
- Deductible
- $912.14 of $1,500.0061%
- Out-of-pocket maximum
- $729.63 of $6,000.0012%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 5160354705
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2026174864 / 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 | $2,160.00 | $1,188.00 | $767.90 | $420.10 | Paid |
| Totals | $2,160.00 | $1,188.00 | $767.90 | $420.10 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-402436
- 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-001796 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-11: CHOICE-PLUS-PPO (PPO), effective 2023-12-01. | |
| 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 PA2026174864 on file for 73721. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (4688502655). | |
| 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 Center2026-01-11 12:21
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026174864_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-01-11 to 2026-04-11.
- Itemized billitemized_PA-402436.pdf4 pages
Itemised statement totalling $2160.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021842 | 2025-12-22 | Pinecrest Clinical Laboratories | $142.00 | Approved |
| CLM-2026-020560 | 2025-11-26 | Canyon Community Hospital | $1,844.00 | Approved |
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.