CLM-2026-004472
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-03-09 at outpatient hospital (POS 22). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Alexis Armstrong
- Member ID
- UHC-43400-99
- Date of birth
- 2004-09-05
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-429566
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8255
- Coverage period
- 2022-01-01 to present
- Deductible
- $174.09 of $500.0035%
- Out-of-pocket maximum
- $273.40 of $1,500.0018%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 6947271592
- Location
- Los Angeles, CA · TIN 56-0316152
- 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,392.00 | $765.60 | — | — | DeniedCO197 |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | 25 | 1 | 2 | $5,695.00 | $3,132.25 | — | — | DeniedCO197 |
| Totals | $7,087.00 | $3,897.85 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-296718
- 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-000445 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-09: N/A (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721, 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-03-09 09:13
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-04-16 00:37
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-296718.pdf7 pages
Itemised statement totalling $7087.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721, 29881 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026829 | 2026-06-03 | Sunrise Medical Group | $483.00 | Approved |
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.