Claims workbench/CLM-2026-004690
Professional claim · CMS-1500 · EDI 837P

CLM-2026-004690

Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-05-23 at office (POS 11). Received 2026-06-28.

Approved
Billed
$293.00
1 line
Allowed
$181.66
contract rate applied
Plan pays
$106.66
approved
Member owes
$75.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Carlos Boyd
Member ID
UHC-50719-93
Date of birth
1983-03-26
Identity
Verified3 records, confidence 0.97
Claim record
CLMCLM-430107
Relationship
Child, Denver, CO

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-5949
Coverage period
2021-07-01 to present
Deductible
$907.65 of $1,500.0061%
Out-of-pocket maximum
$453.94 of $3,000.0015%
Copays
office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits
15 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI
8496214718
Network
In network
Rendering NPI
6168619586
Location
Nashville, TN · TIN 33-7590536
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
120610Joint injection, major joint—11$293.00$181.66$75.00$106.66Paid
Totals$293.00$181.66$75.00$106.66
Diagnoses (ICD-10-CM)
  • 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
Claim header
Patient account
PA-461985
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-020053 (verified, link confidence 0.97).
EligibilityPassActive on 2026-05-23: MEDICARE-ADV-B (MA), effective 2021-07-01.
Timely filingPassReceived 36 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Bone and Joint Center (8496214718).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Bone and Joint Center2026-05-23 17:19

    Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$293.00
Plan discount
$111.34
contracted rate
Plan paid
$106.66
You may owe
$75.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity