CLM-2026-004224
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-10 at outpatient hospital (POS 22). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Kevin Reyes
- Member ID
- UHC-54672-04
- Date of birth
- 1938-04-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422205
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9023
- Coverage period
- 2023-10-01 to 2026-01-18
- Deductible
- $267.79 of $1,000.0027%
- Out-of-pocket maximum
- $1,800.28 of $4,000.0045%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 1052121161
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- PA2026441205 / 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 | $10,780.00 | $5,929.00 | — | — | DeniedCO27 |
| Totals | $10,780.00 | $5,929.00 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-250831
- 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-011072 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-10 is after coverage terminated on 2026-01-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026441205 on file for 29881. | |
| Provider network | Pass | In-network provider Sunrise Orthopedic Specialists (2414063810). | |
| 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 Orthopedic Specialists2026-07-10 16:34
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-08-08 04:16
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-08 14:50
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026441205_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-07-10 to 2026-10-08.
- Itemized billitemized_PA-250831.pdf8 pages
Itemised statement totalling $10780.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-10 is after coverage terminated on 2026-01-18.
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
Service after coverage termination.