Claims workbench/CLM-2026-033331

Institutional claim · UB-04 · EDI 837I

CLM-2026-033331

Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-20 at outpatient hospital (POS 22). Received 2026-09-03.

PendedIdentity on hold: CASE-001124

Billed

$8,411.00

2 lines

Allowed

$4,626.05

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Juan Myers
Member ID: none on golden record
Date of birth: 2000-11-12
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-431914
Relationship: Spouse

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-3042
Coverage period: 2024-02-01 to present
Deductible: $1,026.19 of $2,500.0041%
Out-of-pocket maximum: $2,998.94 of $7,500.0040%
Copays: office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits: 8 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: 6842163423
Location: Phoenix, AZ · TIN 50-3046245
Authorisation / referral: PA2026064948 / REF762634

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	$7,091.00	$3,900.05	—	—	PendedIDQ
2	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1	$1,320.00	$726.00	—	—	PendedIDQ
Totals						$8,411.00	$4,626.05	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-793281
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001124; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-07-20: NAVIGATE-HMO (HMO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 45 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026064948 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)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Patient seen for other tear of medial meniscus, right knee, initial encounter. Note dictat”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Bone and Joint Center2026-07-20 11:28
Patient seen for other tear of medial meniscus, right knee, initial encounter. Note dictated; signature pending.
SystemSystem: Claims system2026-09-03 02:45
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-03 10:38
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026064948_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-07-20 to 2026-10-18.
Itemized billitemized_PA-793281.pdf8 pages
Itemised statement totalling $8411.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-001124; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-20: NAVIGATE-HMO (HMO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Patient seen for other tear of medial meniscus, right knee, initial encounter. Note dictat”.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

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

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity