CLM-2026-006196
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-11 at outpatient hospital (POS 22). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Alan Hoffman
- Member ID
- UHC-11329-12
- Date of birth
- 1983-06-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-411186
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group UNKNOWN
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,434.14 of $3,500.0041%
- Out-of-pocket maximum
- $128.77 of $7,000.002%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 1801463799
- Location
- Tempe, AZ · TIN 82-7144175
- Authorisation / referral
- PA2025561855 / 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 | $1,435.00 | $789.25 | $789.25 | $0.00 | Paid |
| Totals | $1,435.00 | $789.25 | $789.25 | $0.00 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-261231
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008844 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-11: UNKNOWN (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025561855 on file for 73721. | |
| Provider network | Pass | In-network provider Evergreen Orthopedic Specialists (4479500462). | |
| 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: Evergreen Orthopedic Specialists2026-06-11 16:49
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2025561855_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-06-11 to 2026-09-09.
- Itemized billitemized_PA-261231.pdf9 pages
Itemised statement totalling $1435.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006197 | 2026-06-11 | Pinecrest Bone and Joint Center | $1,435.00 | Needs review |
| CLM-2026-006837 | 2026-01-25 | Pinecrest Diagnostic Imaging | $3,558.00 | 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.