CLM-2026-000174
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-04 at outpatient hospital (POS 22). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Amber Larson
- Member ID
- UHC-72250-82
- Date of birth
- 1943-12-22
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-421134
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7112
- Coverage period
- 2025-03-01 to present
- Deductible
- $409.88 of $500.0082%
- Out-of-pocket maximum
- $500.01 of $1,500.0033%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 3309891174
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- PA2026521920 / 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 | $1,595.00 | $877.25 | $326.26 | $550.99 | Paid |
| Totals | $1,595.00 | $877.25 | $326.26 | $550.99 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-904692
- 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-018789 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-04: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026521920 on file for 73721. | |
| Provider network | Pass | In-network provider Sunrise Orthopedic Specialists (2414063810). | |
| 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: Sunrise Orthopedic Specialists2026-06-04 12:58
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026521920_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-06-04 to 2026-09-02.
- Itemized billitemized_PA-904692.pdf3 pages
Itemised statement totalling $1595.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015354 | 2026-06-19 | Valley Medical Group | $320.00 | 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.