Claims workbench/CLM-2026-002085
Institutional claim · UB-04 · EDI 837I

CLM-2026-002085

Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-05-08.

Pended
Billed
$10,369.00
2 lines
Allowed
$5,702.95
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Gerald Hudson
Member ID
none on golden record
Date of birth
1950-12-20
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-402921
Relationship
Self, Tampa, FL

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
1236301101
Location
Phoenix, AZ · TIN 14-5056475
Authorisation / referral
PA2025932322 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
129881
rev 0360
Knee arthroscopy with meniscectomy—11$9,250.00$5,087.50——PendedN30
273721
rev 0610
MRI lower extremity joint without contrast—12$1,119.00$615.45——PendedN30
Totals$10,369.00$5,702.95——
Diagnoses (ICD-10-CM)
  • 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
Claim header
Patient account
PA-876765
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

CheckResultCodeDetail
Member identityPassAttached to MBR-029670 (verified, link confidence 0.97).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 40 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2025932322 on file for 29881, 73721.
Provider networkPassIn-network provider Sunrise Orthopedic Specialists (2414063810).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Specialists2026-03-29 15:03

    Patient seen for other tear of medial meniscus, right knee, initial encounter.

Attachments

Documents received with the claim

  • Prior auth letterPA2025932322_approval.pdf2 pages

    Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-29 to 2026-06-27.

  • Itemized billitemized_PA-876765.pdf7 pages

    Itemised statement totalling $10369.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0017852026-07-08Valley Community Hospital$2,726.00Pended
CLM-2026-0020862026-03-29Sunrise Orthopedic Specialists$10,369.00Denied

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
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity