CLM-2026-002963
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-06-26 to 2026-06-29 at inpatient hospital (POS 21). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Timothy Nichols
- Member ID
- UHC-69187-33
- Date of birth
- 2001-03-11
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-417055
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group N/A
- Coverage period
- 2021-04-01 to present
- Deductible
- $92.60 of $3,500.003%
- Out-of-pocket maximum
- $4,766.67 of $10,500.0045%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 9608086507
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- none / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $30,342.00 | $16,688.10 | — | — | DeniedCO197 |
| Totals | $30,342.00 | $16,688.10 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-419853
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-06-26 to 2026-06-29
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037786 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-26: CHOICE-PLUS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 27447 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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 | Review | HIGH | Billed $30,342.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-06-29 09:59
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-08 00:17
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-08 14:33
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-419853.pdf4 pages
Itemised statement totalling $30342.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $30,342.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.