Professional claim · CMS-1500 · Provider portal
CLM-2026-002921
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-03-22 at office (POS 11). Received 2026-04-25.
Approved
Billed
$152.00
1 line
Allowed
$94.24
contract rate applied
Plan pays
$19.24
approved
Member owes
$75.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Luis McDonald
- Member ID
- UHC-12314-12
- Date of birth
- 1940-06-07
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421775
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2719
- Coverage period
- 2024-01-01 to present
- Deductible
- $436.04 of $2,500.0017%
- Out-of-pocket maximum
- $487.77 of $7,500.007%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1938450750
- Network
- In network
- Rendering NPI
- 8507585809
- Location
- Mesa, AZ · TIN 27-3094451
- Authorisation / referral
- none / none
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 | $152.00 | $94.24 | $75.00 | $19.24 | Paid |
| Totals | $152.00 | $94.24 | $75.00 | $19.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
Claim header
- Patient account
- PA-160127
- 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-021746 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 34 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 (1938450750). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-03-22 17:32
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$152.00
Plan discount
$57.76
contracted rate
Plan paid
$19.24
You may owe
$75.00
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027399 | 2026-07-12 | Meadow Dermatology Clinic | $698.00 | Approved |
| CLM-2026-015711 | 2026-05-04 | Canyon Medical Group | $646.00 | Approved |
| CLM-2026-017483 | 2026-03-19 | Lakeside Medical Group | $322.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
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.