CLM-2026-033079
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Jason Gray
- Member ID
- UHC-15887-53
- Date of birth
- 1983-11-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-419074
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0596
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,277.50 of $1,500.0085%
- Out-of-pocket maximum
- $918.70 of $3,000.0031%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4688502655
- Network
- In network
- Rendering NPI
- 1138879360
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025186672 / 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 | $7,298.00 | $4,013.90 | $1,359.92 | $2,653.98 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,761.00 | $968.55 | $290.57 | $677.98 | Paid |
| Totals | $9,059.00 | $4,982.45 | $1,650.49 | $3,331.96 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-205088
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009250 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-21: MEDICARE-ADV-B (MA), effective 2021-03-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025186672 on file for 29881, 73721. | |
| 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 Center2026-08-21 09:06
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025186672_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-21 to 2026-11-19.
- Itemized billitemized_PA-205088.pdf6 pages
Itemised statement totalling $9059.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033080 | 2026-08-21 | Lakeside Bone and Joint Center | $9,059.00 | Needs review |
| CLM-2026-011042 | 2026-03-23 | Lakeside Bone and Joint Center | $220.00 | 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.