CLM-2026-007909
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2025-12-01 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Tyler Russell
- Member ID
- UHC-38785-33
- Date of birth
- 1958-12-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410590
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7537
- Coverage period
- 2024-11-01 to present
- Deductible
- $809.22 of $1,000.0081%
- Out-of-pocket maximum
- $677.72 of $4,000.0017%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 4106528878
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2025774924 / 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 | $1,743.00 | $958.65 | $421.14 | $537.51 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $5,889.00 | $3,238.95 | $971.69 | $2,267.26 | Paid |
| Totals | $7,632.00 | $4,197.60 | $1,392.83 | $2,804.77 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-225049
- 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-002347 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-01: MEDICARE-ADV-B (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025774924 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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 Center2025-12-01 13:10
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025774924_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-12-01 to 2026-03-01.
- Itemized billitemized_PA-225049.pdf4 pages
Itemised statement totalling $7632.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024933 | 2026-07-12 | Summit Counseling Center | $336.00 | 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.