CLM-2026-006218
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Teresa Fox
- Member ID
- UHC-90462-01
- Date of birth
- 1981-12-23
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-422478
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9650
- Coverage period
- 2023-06-01 to present
- Deductible
- $337.57 of $1,500.0023%
- Out-of-pocket maximum
- $1,767.40 of $4,500.0039%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 5928334817
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2025170013 / REF515260
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 | $1,352.00 | $743.60 | $743.60 | $0.00 | Paid |
| Totals | $1,352.00 | $743.60 | $743.60 | $0.00 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-404140
- 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-012873 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-12: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025170013 on file for 73721. | |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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: Harbor Bone and Joint Center2026-07-12 12:34
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025170013_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-07-12 to 2026-10-10.
- Itemized billitemized_PA-404140.pdf2 pages
Itemised statement totalling $1352.00 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-2026-033451 | 2026-06-21 | Valley Reference Lab | $88.00 | 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.