CLM-2026-002830
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-03-18 at outpatient hospital (POS 22). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Samuel Daniels
- Member ID
- UHC-09665-29
- Date of birth
- 1987-03-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427925
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group UNKNOWN
- Coverage period
- 2021-01-01 to 2026-04-26
- Deductible
- $2,660.64 of $3,500.0076%
- Out-of-pocket maximum
- $1,056.89 of $10,500.0010%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 9322467264
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2025068656 / 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 | $5,920.00 | $3,256.00 | $1,081.02 | $2,174.98 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | 25 | 1 | 1 | $1,719.00 | $945.45 | $94.55 | $850.90 | Paid |
| Totals | $7,639.00 | $4,201.45 | $1,175.57 | $3,025.88 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-887981
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025433 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-18: CHOICE-PLUS-PPO (PPO), effective 2021-01-01, terms 2026-04-26. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025068656 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-03-18 12:48
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2025068656_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-18 to 2026-06-16.
- Itemized billitemized_PA-887981.pdf5 pages
Itemised statement totalling $7639.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.