Professional claim · CMS-1500 · Paper
CLM-2026-024685
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-03 at office (POS 11). Received 2026-01-15.
Approved
Billed
$468.00
2 lines
Allowed
$290.16
contract rate applied
Plan pays
$230.16
approved
Member owes
$60.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Valentina Mejya
- Member ID
- UHC-25585-49
- Date of birth
- 1964-08-16
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-432483
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1951
- Coverage period
- 2021-04-01 to present
- Deductible
- $1,136.97 of $1,500.0076%
- Out-of-pocket maximum
- $211.22 of $4,500.005%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 4912605878
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- none / REF400729
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $217.00 | $134.54 | $60.00 | $74.54 | Paid |
| 2 | 20610 | Joint injection, major joint | — | 1 | 1 | $251.00 | $155.62 | $0.00 | $155.62 | Paid |
| Totals | $468.00 | $290.16 | $60.00 | $230.16 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
Claim header
- Patient account
- PA-709256
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004668 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-03: NAVIGATE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-01-03 17:11
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$468.00
Plan discount
$177.84
contracted rate
Plan paid
$230.16
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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: Clean
Clean claim, priced at contract rate.