Claims workbench/CLM-2026-002062

Institutional claim · UB-04 · EDI 837I

CLM-2026-002062

Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-16 at outpatient hospital (POS 22). Received 2026-04-18.

PendedIdentity on hold: CASE-000406

Billed

$7,604.00

2 lines

Allowed

$4,182.20

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

IDQ, N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Daniel Bennett
Member ID: none on golden record
Date of birth: 2008-08-12
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-414155
Relationship: Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Sunrise Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 2414063810
Network: In network
Rendering NPI: 6849079226
Location: Phoenix, AZ · TIN 14-5056475
Authorisation / referral: PA2026663230 / 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	73721 rev 0610	MRI lower extremity joint without contrast	59	1	1	$1,582.00	$870.10	—	—	PendedIDQ
2	29881 rev 0360	Knee arthroscopy with meniscectomy	59	1	1	$6,022.00	$3,312.10	—	—	PendedIDQ
Totals						$7,604.00	$4,182.20	—	—

Diagnoses (ICD-10-CM)

1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal

Claim header

Patient account: PA-715552
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-000406; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 2 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026663230 on file for 73721, 29881.
Provider network	Pass		In-network provider Sunrise Orthopedic Specialists (2414063810).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Orthopedic Specialists2026-04-16 11:24
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-04-18 06:00
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-18 13:05
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026663230_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-04-16 to 2026-07-15.
Itemized billitemized_PA-715552.pdf6 pages
Itemised statement totalling $7604.00 across 2 lines.
Medical recordrecords_PA-715552.pdf18 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000406; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity