CLM-2026-001997
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-08-19 at office (POS 11). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Stephen Murray
- Member ID
- UHC-92761-01
- Date of birth
- 1962-05-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-432794
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5620
- Coverage period
- 2022-10-01 to 2026-02-11
- Deductible
- $1,076.81 of $1,500.0072%
- Out-of-pocket maximum
- $2,096.84 of $4,500.0047%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 6588637796
- Location
- Scottsdale, AZ · TIN 78-6151009
- Authorisation / referral
- none / REF614223
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $162.00 | $100.44 | — | — | DeniedCO27 |
| Totals | $162.00 | $100.44 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-510206
- 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-012594 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-19 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (8824040173). | |
| 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: Pinecrest Bone and Joint Center2026-08-19 16:29
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-12 06:50
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-12 09:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-19 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006907 | 2026-07-13 | Valley Imaging Center | $4,713.00 | Denied |
| CLM-2026-020830 | 2026-06-21 | Sunrise Internal Medicine Associates | $238.00 | Denied |
| CLM-2026-029607 | 2026-05-24 | Sunrise Counseling Center | $585.00 | Denied |
| CLM-2026-008987 | 2026-01-26 | Mesa Internal Medicine Associates | $44.00 | 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
Service after coverage termination.