CLM-2026-033722
Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-13 at outpatient hospital (POS 22). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Bill Reynolds
- Member ID
- UHC-07356-49
- Date of birth
- 1951-06-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415417
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8877
- Coverage period
- 2023-03-01 to present
- Deductible
- $2,673.90 of $3,500.0076%
- Out-of-pocket maximum
- $5,126.01 of $14,000.0037%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- 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
- 6499498619
- Location
- Austin, TX · TIN 36-5200643
- Authorisation / referral
- PA2025598180 / 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 | $9,307.00 | $5,118.85 | $2,113.93 | $3,004.92 | Paid |
| Totals | $9,307.00 | $5,118.85 | $2,113.93 | $3,004.92 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-455530
- 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-009155 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-13: SELECT-EPO (EPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025598180 on file for 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 Center2026-01-13 17:40
Patient seen for unilateral primary osteoarthritis, left knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025598180_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-13 to 2026-04-13.
- Itemized billitemized_PA-455530.pdf2 pages
Itemised statement totalling $9307.00 across 1 line.
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-2026-033723 | 2026-01-13 | Lakeside Bone and Joint Center | $9,307.00 | Needs review |
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.