CLM-2026-003382
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-16 at outpatient hospital (POS 22). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Stephanie Reed
- Member ID
- UHC-97234-36
- Date of birth
- 1993-01-10
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-410130
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3167
- Coverage period
- 2022-10-01 to present
- Deductible
- $591.49 of $1,000.0059%
- Out-of-pocket maximum
- $100.81 of $3,000.003%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 2894971565
- Location
- Tempe, AZ · TIN 82-7144175
- Authorisation / referral
- PA2025225521 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,771.00 | $974.05 | $465.06 | $508.99 | Paid |
| Totals | $1,771.00 | $974.05 | $465.06 | $508.99 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-602247
- 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-002713 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-16: CHOICE-PLUS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025225521 on file for 73721. | |
| Provider network | Pass | In-network provider Evergreen Orthopedic Specialists (4479500462). | |
| 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: Evergreen Orthopedic Specialists2025-12-16 09:28
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025225521_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-12-16 to 2026-03-16.
- Itemized billitemized_PA-602247.pdf5 pages
Itemised statement totalling $1771.00 across 1 line.
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.