CLM-2026-024426
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-09-14 at outpatient hospital (POS 22). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Gregory Gonzales
- Member ID
- UHC-76342-42
- Date of birth
- 1961-02-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428949
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5571
- Coverage period
- 2021-12-01 to 2026-01-06
- Deductible
- $720.08 of $1,000.0072%
- Out-of-pocket maximum
- $1,553.55 of $4,000.0039%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 4799430192
- Location
- Nashville, TN · TIN 22-6450141
- Authorisation / referral
- PA2025948178 / 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 | $5,649.00 | $3,106.95 | — | — | DeniedCO27 |
| Totals | $5,649.00 | $3,106.95 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-877975
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000353; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-09-14 is after coverage terminated on 2026-01-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025948178 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 Center2026-09-14 18:59
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-17 05:41
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-17 09:43
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025948178_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-09-14 to 2026-12-13.
- Itemized billitemized_PA-877975.pdf5 pages
Itemised statement totalling $5649.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000353; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-09-14 is after coverage terminated on 2026-01-06.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.