CLM-2026-001587
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-02-01 at outpatient hospital (POS 22). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Christopher Stevens
- Member ID
- UHC-44226-46
- Date of birth
- 1992-09-21
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-429110
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0493
- Coverage period
- 2021-07-01 to present
- Deductible
- $193.48 of $1,000.0019%
- Out-of-pocket maximum
- $773.26 of $2,000.0039%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 3563258318
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- PA2025557473 / 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 | $9,576.00 | $5,266.80 | — | — | Review |
| Totals | $9,576.00 | $5,266.80 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-575021
- 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-014505 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-01: MEDICARE-ADV-B (MA), effective 2021-07-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025557473 on file for 29881. | |
| Provider network | Pass | In-network provider Sunrise Bone and Joint Center (8496214718). | |
| 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: “Patient seen for unilateral primary osteoarthritis, right knee. Note dictated; signature p”. 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: Sunrise Bone and Joint Center2026-02-01 11:46
Patient seen for unilateral primary osteoarthritis, right knee. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-20 06:50
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-20 11:48
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025557473_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-01 to 2026-05-02.
- Itemized billitemized_PA-575021.pdf6 pages
Itemised statement totalling $9576.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for unilateral primary osteoarthritis, right knee. Note dictated; signature p”.
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.