CLM-2026-027020
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-16 at outpatient hospital (POS 22). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Santiago Reed
- Member ID
- UHC-53248-15
- Date of birth
- 2005-06-26
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412012
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2721
- Coverage period
- 2021-09-01 to 2026-08-20
- Deductible
- $687.34 of $1,000.0069%
- Out-of-pocket maximum
- $741.80 of $3,000.0025%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9892398337
- Network
- In network
- Rendering NPI
- 2456005588
- Location
- Nashville, TN · TIN 22-6450141
- Authorisation / referral
- PA2025285927 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $7,109.00 | $3,909.95 | — | — | Review |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 2 | $1,175.00 | $646.25 | — | — | Review |
| Totals | $8,284.00 | $4,556.20 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-736017
- 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-042574 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-16: MEDICARE-ADV-A (MA), effective 2021-09-01, terms 2026-08-20. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025285927 on file for 29881, 73721. | |
| 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 | Review | CO16 | Documentation incomplete: “Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-08-16 11:34
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-26 01:11
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-26 08:59
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025285927_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-16 to 2026-11-14.
- Itemized billitemized_PA-736017.pdf9 pages
Itemised statement totalling $8284.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications re”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.