CLM-2026-024693
Lakeside Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-20 at outpatient hospital (POS 22). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Lawrence Hamilton
- Member ID
- UHC-23883-35
- Date of birth
- 1949-01-17
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-405354
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5423
- Coverage period
- 2022-05-01 to present
- Deductible
- $992.18 of $1,500.0066%
- Out-of-pocket maximum
- $291.79 of $4,500.006%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6175341661
- Network
- In network
- Rendering NPI
- 3631263340
- Location
- San Diego, CA · TIN 92-6249364
- Authorisation / referral
- none / 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 | $2,351.00 | $1,293.05 | — | — | DeniedCO197 |
| Totals | $2,351.00 | $1,293.05 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-510614
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-004479 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-20: - (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Lakeside Orthopedic Specialists (6175341661). | |
| 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 Orthopedic Specialists2026-01-20 10:11
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-03 01:42
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-03 14:17
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-510614.pdf5 pages
Itemised statement totalling $2351.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 73721 require precertification; no authorisation number on the claim.
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
Precertification required and absent.