CLM-2026-032279
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Andrew Little
- Member ID
- UHC-87409-19
- Date of birth
- 1958-05-10
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403119
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7751
- Coverage period
- 2023-05-01 to present
- Deductible
- $537.48 of $1,500.0036%
- Out-of-pocket maximum
- $1,351.02 of $4,500.0030%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 3420909210
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025778988 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,922.00 | $1,057.10 | $981.44 | $75.66 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1,2 | $10,736.00 | $5,904.80 | $1,180.96 | $4,723.84 | Paid |
| Totals | $12,658.00 | $6,961.90 | $2,162.40 | $4,799.50 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-176330
- 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-012874 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-09: OPTIONS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025778988 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Lakeside Bone and Joint Center (4688502655). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Bone and Joint Center2026-08-09 09:50
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025778988_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-08-09 to 2026-11-07.
- Itemized billitemized_PA-176330.pdf8 pages
Itemised statement totalling $12658.00 across 2 lines.
Explanation of benefits
What the member will see
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-2026-002517 | 2026-07-24 | Sunrise Dermatology Clinic | $959.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.