CLM-2026-000322
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-03-01 at outpatient hospital (POS 22). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Austin Lucas
- Member ID
- none on golden record
- Date of birth
- 1968-09-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431191
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-8964
- Coverage period
- 2023-05-01 to 2026-06-02
- Deductible
- $1,574.24 of $3,500.0045%
- Out-of-pocket maximum
- $1,861.67 of $14,000.0013%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 7037353795
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2026323529 / REF823572
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 | $8,789.00 | $4,833.95 | — | — | PendedIDQ |
| Totals | $8,789.00 | $4,833.95 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-314491
- 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-002925; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-01: NAVIGATE-HMO (HMO), effective 2023-05-01, terms 2026-06-02. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026323529 on file for 29881. | |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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: “Established patient presents with unilateral primary osteoarthritis, right knee; symptoms ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Bone and Joint Center2026-03-01 11:38
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-24 06:28
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2026323529_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-01 to 2026-05-30.
- Itemized billitemized_PA-314491.pdf2 pages
Itemised statement totalling $8789.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002925; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-01: NAVIGATE-HMO (HMO), effective 2023-05-01, terms 2026-06-02. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Established patient presents with unilateral primary osteoarthritis, right knee; symptoms ”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.