Claims workbench/CLM-2026-002086

Institutional claim · UB-04 · EDI 837I

CLM-2026-002086

Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-05-17.

Denied

Billed

$10,369.00

2 lines

Allowed

$5,702.95

if approved

Plan pays

—

Denied

Member owes

—

no coverage

Rules engine

Deny

CO18

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

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	29881 rev 0360	Knee arthroscopy with meniscectomy	—	1	1	$9,250.00	$5,087.50	—	—	DeniedCO18
2	73721 rev 0610	MRI lower extremity joint without contrast	—	1	2	$1,119.00	$615.45	—	—	DeniedCO18
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, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-029670 (verified, link confidence 0.97).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 49 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-002085: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025932322 on file for 29881, 73721.
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.

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

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Orthopedic Specialists2026-03-29 11:35
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-05-17 00:49
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-17 10:45
Reviewed with the member's history on file. Holding for the items listed above.

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.pdf4 pages
Itemised statement totalling $10369.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-002085: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-001785	2026-07-08	Valley Community Hospital	$2,726.00	Pended
CLM-2026-002085	2026-03-29	Sunrise Orthopedic Specialists	$10,369.00	Pended

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity