CLM-2026-025342
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2025-11-29 to 2025-12-03 at inpatient hospital (POS 21). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Carolyn Lawrence
- Member ID
- UHC-82629-05
- Date of birth
- 1947-01-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-426880
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6836
- Coverage period
- 2023-11-01 to present
- Deductible
- $781.16 of $2,500.0031%
- Out-of-pocket maximum
- $63.03 of $10,000.001%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 7294378287
- Location
- Nashville, TN · TIN 22-6450141
- Authorisation / referral
- PA2025281989 / 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 | $44,424.00 | $24,433.20 | — | — | Review |
| Totals | $44,424.00 | $24,433.20 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-388701
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-11-29 to 2025-12-02
- 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-000042 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-29: MEDICARE-ADV-A (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025281989 on file for 27447. | |
| 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 | Review | HIGH | Billed $44,424.00 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 Center2025-12-03 13:45
Patient seen for pain in right knee. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-01 03:48
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-01 09:24
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025281989_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-11-29 to 2026-02-27.
- Itemized billitemized_PA-388701.pdf3 pages
Itemised statement totalling $44424.00 across 1 line.
- Medical recordrecords_PA-388701.pdf10 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $44,424.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-21 14:05The claim for a total knee arthroplasty is supported by the member's active coverage [COV], in-network provider status [PRV], and prior authorisation [A1]. The clinical note [N1] and medical record [A3] confirm the procedure was completed without complication. Although the billed amount [L1] exceeds the auto-adjudication ceiling [R-high_dollar], all other deterministic rules have passed, and the claim is complete [R-completeness]. The examiner sign-off is required due to the high-dollar amount [N2].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · c57ac866
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for a total knee arthroplasty is supported by the member's active coverage [COV], in-network provider status [PRV], and prior authorisation [A1]. The clinical note [N1] and medical record [A3] confirm the procedure was completed without complication. Although the billed amount [L1] exceeds the auto-adjudication ceiling [R-high_dollar], all other deterministic rules have passed, and the claim is complete [R-completeness]. The examiner sign-off is required due to the high-dollar amount [N2].
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
Above auto-pay ceiling; payable once an examiner signs off.