CLM-2026-004592
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-04-24 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Zachary Carpenter
- Member ID
- UHC-74272-06
- Date of birth
- 1946-09-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-404105
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7191
- Coverage period
- 2023-08-01 to present
- Deductible
- $826.31 of $1,500.0055%
- Out-of-pocket maximum
- $16.94 of $6,000.000%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 6493983541
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2026385040 / 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 | $7,056.00 | $3,880.80 | $1,635.82 | $2,244.98 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,319.00 | $725.45 | $217.64 | $507.81 | Paid |
| Totals | $8,375.00 | $4,606.25 | $1,853.46 | $2,752.79 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-638909
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000629 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-24: OPTIONS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026385040 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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: Pinecrest Bone and Joint Center2026-04-24 15:24
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026385040_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-24 to 2026-07-23.
- Itemized billitemized_PA-638909.pdf2 pages
Itemised statement totalling $8375.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002768 | 2026-07-20 | Sunrise Digestive Health Center | $2,510.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.