Professional claim · CMS-1500 · EDI 837P
CLM-2026-031961
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-03-20 at office (POS 11). Received 2026-05-04.
Approved
Billed
$407.00
2 lines
Allowed
$252.34
contract rate applied
Plan pays
$212.34
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jesse Barnes
- Member ID
- UHC-14334-26
- Date of birth
- 1969-03-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416503
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4283
- Coverage period
- 2021-03-01 to present
- Deductible
- $449.14 of $500.0090%
- Out-of-pocket maximum
- $512.26 of $2,000.0026%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2952838284
- Network
- In network
- Rendering NPI
- 1790964641
- Location
- Phoenix, AZ · TIN 50-3046245
- Authorisation / referral
- none / REF924671
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $191.00 | $118.42 | $40.00 | $78.42 | Paid |
| 2 | 20610 | Joint injection, major joint | — | 1 | 2 | $216.00 | $133.92 | $0.00 | $133.92 | Paid |
| Totals | $407.00 | $252.34 | $40.00 | $212.34 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
Claim header
- Patient account
- PA-711679
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006096 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-20: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-03-20 09:44
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$407.00
Plan discount
$154.66
contracted rate
Plan paid
$212.34
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004537 | 2026-05-26 | Sunrise Digestive Health Center | $204.00 | Denied |
| CLM-2026-004536 | 2026-05-26 | Unity Digestive Health Center | $204.00 | Approved |
| CLM-2026-031962 | 2026-03-20 | Valley Bone and Joint Center | $407.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.