CLM-2026-009192
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-02 at outpatient hospital (POS 22). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Gerald McDonald
- Member ID
- UHC-64585-32
- Date of birth
- 1968-02-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400732
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0313
- Coverage period
- 2021-10-01 to present
- Deductible
- $2,124.04 of $3,500.0061%
- Out-of-pocket maximum
- $1,799.69 of $10,500.0017%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 1924356656
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2026744671 / 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 | $1,309.00 | $719.95 | $719.95 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | 25 | 1 | 1 | $7,782.00 | $4,280.10 | $1,018.42 | $3,261.68 | Paid |
| Totals | $9,091.00 | $5,000.05 | $1,738.37 | $3,261.68 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-631039
- 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-027507 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: - (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026744671 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 Center2026-05-02 09:22
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026744671_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-02 to 2026-07-31.
- Itemized billitemized_PA-631039.pdf4 pages
Itemised statement totalling $9091.00 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-2026-012306 | 2026-07-03 | Valley Reference Lab | $91.00 | 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.