CLM-2026-007746
Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Olivia Olivia
- Member ID
- UHC-83341-11
- Date of birth
- 1950-06-10
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-400897
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9165
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,434.57 of $2,500.0057%
- Out-of-pocket maximum
- $232.87 of $7,500.003%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3819335712
- Network
- In network
- Rendering NPI
- 7445375299
- Location
- Tampa, FL · TIN 32-1762387
- Authorisation / referral
- PA2025552697 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $7,350.00 | $4,042.50 | $1,363.14 | $2,679.36 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,418.00 | $779.90 | $77.99 | $701.91 | Paid |
| Totals | $8,768.00 | $4,822.40 | $1,441.13 | $3,381.27 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-808753
- 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-012528 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-B (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025552697 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Heritage Orthopedic Specialists (3819335712). | |
| 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: Heritage Orthopedic Specialists2026-02-13 14:50
Patient seen for unilateral primary osteoarthritis, left knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025552697_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-13 to 2026-05-14.
- Itemized billitemized_PA-808753.pdf2 pages
Itemised statement totalling $8768.00 across 2 lines.
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
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.