CLM-2026-001099
Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-03 at outpatient hospital (POS 22). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Pamela Hicks
- Member ID
- UHC-52905-09
- Date of birth
- 1951-06-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408260
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1938
- Coverage period
- 2024-12-01 to 2026-07-12
- Deductible
- $234.09 of $2,500.009%
- Out-of-pocket maximum
- $2,697.35 of $7,500.0036%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3819335712
- Network
- In network
- Rendering NPI
- 7109681990
- Location
- Tampa, FL · TIN 32-1762387
- Authorisation / referral
- PA2026882328 / 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 | $8,337.00 | $4,585.35 | $2,961.74 | $1,623.61 | Paid |
| Totals | $8,337.00 | $4,585.35 | $2,961.74 | $1,623.61 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-348935
- 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-001296 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-03: CHOICE-PLUS-PPO (PPO), effective 2024-12-01, terms 2026-07-12. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026882328 on file for 29881. | |
| Provider network | Pass | In-network provider Heritage Orthopedic Specialists (3819335712). | |
| 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: Heritage Orthopedic Specialists2026-04-03 10:43
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026882328_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-03 to 2026-07-02.
- Itemized billitemized_PA-348935.pdf4 pages
Itemised statement totalling $8337.00 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-2026-008984 | 2026-07-06 | Evergreen Clinical Laboratories | $196.00 | Denied |
| CLM-2026-008983 | 2026-07-06 | Evergreen Clinical Laboratories | $196.00 | 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.