CLM-2026-001141
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-08-25.
Member
Resolved through the identity graph
- Member
- Elijah Wells
- Member ID
- UHC-60287-08
- Date of birth
- 2007-01-01
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-423210
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7842
- Coverage period
- 2022-06-01 to present
- Deductible
- $234.89 of $1,500.0016%
- Out-of-pocket maximum
- $843.78 of $4,500.0019%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 4897135842
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- none / REF517788
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 | $9,019.00 | $4,960.45 | — | — | DeniedCO197 |
| Totals | $9,019.00 | $4,960.45 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-828727
- 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-018398 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-21: NAVIGATE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Specialists2026-08-21 18:53
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-25 02:32
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-828727.pdf2 pages
Itemised statement totalling $9019.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023576 | 2026-08-19 | Heritage Primary Care Associates | $143.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.