CLM-2026-007899
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-03-14 at outpatient hospital (POS 22). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Rick Chavez
- Member ID
- UHC-25871-69
- Date of birth
- 1969-11-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431597
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2677
- Coverage period
- 2021-10-01 to present
- Deductible
- $817.85 of $1,500.0055%
- Out-of-pocket maximum
- $2,083.04 of $6,000.0035%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 5443347336
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2026425429 / 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 | $1,249.00 | $686.95 | $682.63 | $4.32 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,101.00 | $4,455.55 | $445.56 | $4,009.99 | Paid |
| Totals | $9,350.00 | $5,142.50 | $1,128.19 | $4,014.31 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-450740
- 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-021589 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-14: CHOICE-PLUS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026425429 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (3990196263). | |
| 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 Center2026-03-14 11:18
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026425429_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-14 to 2026-06-12.
- Itemized billitemized_PA-450740.pdf2 pages
Itemised statement totalling $9350.00 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.