Professional claim · CMS-1500 · EDI 837P
CLM-2026-000055
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-06-21 at office (POS 11). Received 2026-07-09.
ApprovedOut of network
Billed
$262.00
1 line
Allowed
$117.90
contract rate applied
Plan pays
$42.90
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jesse Peterson
- Member ID
- UHC-22892-68
- Date of birth
- 1963-11-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427685
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4256
- Coverage period
- 2021-11-01 to present
- Deductible
- $955.97 of $2,500.0038%
- Out-of-pocket maximum
- $353.98 of $7,500.005%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 2158757908
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- none / none
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 | 20610 | Joint injection, major joint | — | 1 | 1 | $262.00 | $117.90 | $75.00 | $42.90 | Paid |
| Totals | $262.00 | $117.90 | $75.00 | $42.90 | ||||||
Diagnoses (ICD-10-CM)
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M25.561 Pain in right knee
Claim header
- Patient account
- PA-556403
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003718 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-21: CHOICE-PLUS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Bone and Joint Center2026-06-21 18:01
Patient seen for unilateral primary osteoarthritis, left knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$262.00
Plan discount
$144.10
out-of-network allowance
Plan paid
$42.90
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020466 | 2026-08-09 | Pinecrest Behavioral Health | $250.00 | Needs review |
| CLM-2026-020465 | 2026-08-09 | Sunrise Behavioral Health | $250.00 | Approved |
| CLM-2026-010120 | 2025-11-28 | Canyon Regional Medical Center | $216.00 | Approved |
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.