CLM-2026-003047
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-02-26 at outpatient hospital (POS 22). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Bobby Murphy
- Member ID
- UHC-47074-60
- Date of birth
- 1992-04-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419972
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2024-03-01 to present
- Deductible
- $848.10 of $1,000.0085%
- Out-of-pocket maximum
- $1,373.13 of $3,000.0046%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1938450750
- Network
- In network
- Rendering NPI
- 8211550156
- Location
- Mesa, AZ · TIN 27-3094451
- Authorisation / referral
- PA2026659177 / 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 | $9,989.00 | $5,493.95 | — | — | Review |
| Totals | $9,989.00 | $5,493.95 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-741827
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017715 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-26: NULL (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-003046, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | Authorisation PA2026659177 on file for 29881. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-02-26 16:21
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-14 00:58
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-14 12:04
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026659177_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-26 to 2026-05-27.
- Itemized billitemized_PA-741827.pdf8 pages
Itemised statement totalling $9989.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-003046, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003046 | 2026-02-26 | Riverside Bone and Joint Center | $9,989.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.