Claims workbench/CLM-2026-031916

Institutional claim · UB-04 · Paper

CLM-2026-031916

Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-04-05 at outpatient hospital (POS 22). Received 2026-04-21.

Denied

Billed

$11,710.00

2 lines

Allowed

$6,440.50

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Lawrence Wrihgt
Member ID: UHC-13959-33
Date of birth: 1939-01-02
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-408886
Relationship: Spouse, Plano, TX

Coverage and accumulators

Found by member ID

Plan: UNKNOWN PPO group N/A
Coverage period: 2021-04-01 to 2026-03-26
Deductible: $291.95 of $1,000.0029%
Out-of-pocket maximum: $57.02 of $2,000.003%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 2 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 2952838284
Network: In network
Rendering NPI: 1046464909
Location: Phoenix, AZ · TIN 50-3046245
Authorisation / referral: PA2026302126 / 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	59	1	1	$9,634.00	$5,298.70	—	—	DeniedCO27
2	73721 rev 0610	MRI lower extremity joint without contrast	59	1	2	$2,076.00	$1,141.80	—	—	DeniedCO27
Totals						$11,710.00	$6,440.50	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter

Claim header

Patient account: PA-675481
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-008342 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-04-05 is after coverage terminated on 2026-03-26. Expenses incurred after coverage terminated
Timely filing	Pass		Received 16 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026302126 on file for 29881, 73721.
Provider network	Pass		In-network provider Lakeside Bone and Joint Center (2952838284).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Bone and Joint Center2026-04-05 17:24
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-04-21 06:55

Attachments

Documents received with the claim

Prior auth letterPA2026302126_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-05 to 2026-07-04.
Itemized billitemized_PA-675481.pdf3 pages
Itemised statement totalling $11710.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-04-05 is after coverage terminated on 2026-03-26. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-013076	2026-01-06	Pinecrest Bone and Joint Center	$10,675.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity