CLM-2026-028090
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-28 to 2026-07-30 at inpatient hospital (POS 21). Received 2026-08-06.
Member
Resolved through the identity graph
- Member
- Jose Day
- Member ID
- UHC-65678-01
- Date of birth
- 2004-10-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-429316
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9817
- Coverage period
- 2025-11-01 to present
- Deductible
- $2,284.00 of $3,500.0065%
- Out-of-pocket maximum
- $4,685.49 of $10,500.0045%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 1902241938
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- PA2026617954 / 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 | $49,064.00 | $26,985.20 | — | — | Review |
| Totals | $49,064.00 | $26,985.20 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-919462
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-07-28 to 2026-08-01
- 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-034469 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-28: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026617954 on file for 27447. | |
| 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 | Review | HIGH | Billed $49,064.00 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 Center2026-07-30 10:40
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026617954_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-07-28 to 2026-10-26.
- Itemized billitemized_PA-919462.pdf6 pages
Itemised statement totalling $49064.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $49,064.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028091 | 2026-07-28 | Lakeside Bone and Joint Center | $49,064.00 | Denied |
| CLM-2026-028053 | 2026-07-08 | Mesa Physical Therapy | $316.00 | Denied |
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
Clean claim, priced at contract rate.