CLM-2026-004070
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Nicole Rivera
- Member ID
- none on golden record
- Date of birth
- 1941-03-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401672
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NULL PPO group N/A
- Coverage period
- 2023-02-01 to present
- Deductible
- $53.17 of $2,500.002%
- Out-of-pocket maximum
- $1,298.81 of $7,500.0017%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 9874515635
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- PA2025143819 / 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 | $7,234.00 | $3,978.70 | — | — | PendedIDQ |
| Totals | $7,234.00 | $3,978.70 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-536940
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000388; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-06: NULL (PPO), effective 2023-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025143819 on file for 29881. | |
| Provider network | Pass | In-network provider Sunrise Bone and Joint Center (8496214718). | |
| 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: Sunrise Bone and Joint Center2026-05-06 15:06
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025143819_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-06 to 2026-08-04.
- Itemized billitemized_PA-536940.pdf8 pages
Itemised statement totalling $7234.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000388; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-06: NULL (PPO), effective 2023-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.