CLM-2026-003844
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-01 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Benjamin Brooks
- Member ID
- UHC-58222-55
- Date of birth
- 2008-12-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422823
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4400
- Coverage period
- 2024-10-01 to present
- Deductible
- $772.54 of $1,000.0077%
- Out-of-pocket maximum
- $32.27 of $4,000.001%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 7518279915
- Location
- Tempe, AZ · TIN 82-7144175
- 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,428.00 | $5,735.40 | — | — | DeniedCO197 |
| Totals | $10,428.00 | $5,735.40 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-942925
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003394 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-01: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Specialists2025-12-01 14:27
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-01-11 03:38
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-11 13:46
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-942925.pdf9 pages
Itemised statement totalling $10428.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 require precertification; no authorisation number on the claim.
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.