CLM-2026-004748
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-08-04 at outpatient hospital (POS 22). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Evelyn Hawkins
- Member ID
- UHC-71285-92
- Date of birth
- 1945-07-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414637
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6415
- Coverage period
- 2021-12-01 to 2026-08-15
- Deductible
- $438.82 of $1,000.0044%
- Out-of-pocket maximum
- $1,619.56 of $4,000.0040%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 4003452776
- Location
- Scottsdale, AZ · TIN 78-6151009
- Authorisation / referral
- PA2026716261 / REF912849
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 | $10,464.00 | $5,755.20 | $1,080.58 | $4,674.62 | Paid |
| Totals | $10,464.00 | $5,755.20 | $1,080.58 | $4,674.62 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-852119
- 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-019493 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-04: CORE-HMO (HMO), effective 2021-12-01, terms 2026-08-15. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026716261 on file for 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (8824040173). | |
| 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 Center2026-08-04 16:53
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026716261_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-04 to 2026-11-02.
- Itemized billitemized_PA-852119.pdf4 pages
Itemised statement totalling $10464.00 across 1 line.
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-2026-030922 | 2025-11-02 | Canyon Counseling Center | $458.00 | Denied |
| CLM-2026-022858 | 2026-01-28 | Mesa Imaging Center | $438.00 | Denied |
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.