CLM-2026-025148
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-06-09 at outpatient hospital (POS 22). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Joseph Lucas
- Member ID
- UHC-13804-58
- Date of birth
- 1963-11-28
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-430862
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8004
- Coverage period
- 2022-02-01 to present
- Deductible
- $40.76 of $3,500.001%
- Out-of-pocket maximum
- $849.63 of $7,000.0012%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 6549715152
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2026958454 / REF564680
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 | $6,879.00 | $3,783.45 | $3,556.50 | $226.95 | Paid |
| Totals | $6,879.00 | $3,783.45 | $3,556.50 | $226.95 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-345350
- 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-028599 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-09: NAVIGATE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026958454 on file for 29881. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (2952838284). | |
| 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 Center2026-06-09 17:02
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026958454_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-06-09 to 2026-09-07.
- Itemized billitemized_PA-345350.pdf5 pages
Itemised statement totalling $6879.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006236 | 2026-04-01 | Summit Regional Medical Center | $3,266.00 | Denied |
| CLM-2026-006235 | 2026-04-01 | Summit Regional Medical Center | $3,266.00 | 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.