CLM-2026-007356
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-01-17 at outpatient hospital (POS 22). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Patrick Castillo
- Member ID
- UHC-12275-94
- Date of birth
- 1989-01-01
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-404685
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2023-01-01 to present
- Deductible
- $179.67 of $500.0036%
- Out-of-pocket maximum
- $44.78 of $1,000.004%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 1651501250
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2025252559 / REF444198
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 | $7,650.00 | $4,207.50 | — | — | DeniedCO18 |
| Totals | $7,650.00 | $4,207.50 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-735084
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017242 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-17: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 56 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-007355: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025252559 on file for 29881. | |
| 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 Center2026-01-17 10:56
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-03-14 02:51
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2025252559_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-17 to 2026-04-17.
- Itemized billitemized_PA-735084.pdf6 pages
Itemised statement totalling $7650.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-007355: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007355 | 2026-01-17 | Harbor Bone and Joint Center | $7,650.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.