Claims workbench/CLM-2026-004313

Institutional claim · UB-04 · EDI 837I

CLM-2026-004313

Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-04-17 at outpatient hospital (POS 22). Received 2026-04-24.

Denied

Billed

$14,882.00

3 lines

Allowed

$8,185.10

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Susan Boyd
Member ID: UHC-70334-03
Date of birth: 1977-11-01
Identity: Verified3 records, confidence 0.96
Claim record: CLMCLM-429503
Relationship: Self, Gilbert, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-1213
Coverage period: 2023-07-01 to 2026-04-16
Deductible: $1,659.70 of $3,500.0047%
Out-of-pocket maximum: $2,278.36 of $14,000.0016%
Copays: office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3990196263
Network: In network
Rendering NPI: 1435632462
Location: Denver, CO · TIN 27-9633140
Authorisation / referral: PA2025686775 / 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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$3,579.00	$1,968.45	—	—	DeniedCO27
2	29881 rev 0360	Knee arthroscopy with meniscectomy	—	1	2	$9,016.00	$4,958.80	—	—	DeniedCO27
3	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1	$2,287.00	$1,257.85	—	—	DeniedCO27
Totals						$14,882.00	$8,185.10	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-869459
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-016015 (verified, link confidence 0.96).
Eligibility	Fail	CO27	Date of service 2026-04-17 is after coverage terminated on 2026-04-16. Expenses incurred after coverage terminated
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 PA2025686775 on file for 70553, 29881, 73721.
Provider network	Pass		In-network provider Pinecrest Bone and Joint Center (3990196263).
Medical necessity	Review	CO50	70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Bone and Joint Center2026-04-17 15:04
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-04-24 01:50
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-24 15:56
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025686775_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-17 to 2026-07-16.
Itemized billitemized_PA-869459.pdf7 pages
Itemised statement totalling $14882.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-04-17 is after coverage terminated on 2026-04-16. Medical necessity: 70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-010217	2026-07-20	Sunrise Digestive Health Center	$2,460.00	Denied

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity