CLM-2026-008039
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-01 at outpatient hospital (POS 22). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Heather Pena
- Member ID
- UHC-96232-44
- Date of birth
- 2004-03-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-426371
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-8285
- Coverage period
- 2021-12-01 to present
- Deductible
- $383.05 of $1,500.0026%
- Out-of-pocket maximum
- $379.23 of $3,000.0013%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 5354379104
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- none / 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 | $2,253.00 | $1,239.15 | — | — | DeniedCO197 |
| Totals | $2,253.00 | $1,239.15 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-936518
- 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-028567 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-01: UNKNOWN (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Sunrise Orthopedic Specialists (2414063810). | |
| 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: Sunrise Orthopedic Specialists2026-06-01 13:41
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-06-18 00:23
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-936518.pdf8 pages
Itemised statement totalling $2253.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.