CLM-2026-024559
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-26 to 2026-08-29 at inpatient hospital (POS 21). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Hiroshi Schultz
- Member ID
- UHC-49624-39
- Date of birth
- 1978-07-23
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422231
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0570
- Coverage period
- 2023-05-01 to present
- Deductible
- $563.36 of $1,500.0038%
- Out-of-pocket maximum
- $874.85 of $6,000.0015%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 2412482301
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025073063 / 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 | $36,744.00 | $20,209.20 | — | — | Review |
| Totals | $36,744.00 | $20,209.20 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-865250
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-08-26 to 2026-08-27
- 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-015745 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-26: NULL (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025073063 on file for 27447. | |
| 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 | Review | HIGH | Billed $36,744.00 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 Center2026-08-29 16:45
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025073063_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-08-26 to 2026-11-24.
- Itemized billitemized_PA-865250.pdf8 pages
Itemised statement totalling $36744.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $36,744.00 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-2026-024560 | 2026-08-26 | Lakeside Bone and Joint Center | $36,744.00 | Needs review |
| CLM-2026-003310 | 2026-01-30 | Valley Reference Lab | $140.00 | Approved |
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.