Claims workbench/CLM-2026-009674

Institutional claim · UB-04 · EDI 837I

CLM-2026-009674

Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-18 to 2026-05-20 at inpatient hospital (POS 21). Received 2026-07-03.

Denied

Billed

$28,762.00

1 line

Allowed

$15,819.10

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: James Burke
Member ID: UHC-47425-07
Date of birth: 1947-01-12
Identity: Verified4 records, confidence 0.88
Claim record: CLMCLM-408417
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-4283
Coverage period: 2021-07-01 to present
Deductible: $1,886.67 of $2,500.0075%
Out-of-pocket maximum: $2,055.59 of $7,500.0027%
Copays: office $40.00, specialist $40.00, emergency $250.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3819335712
Network: In network
Rendering NPI: 5832365436
Location: Tampa, FL · TIN 32-1762387
Authorisation / referral: PA2026219304 / REF549602

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	27447 rev 0360	Total knee arthroplasty	—	1	1	$28,762.00	$15,819.10	—	—	DeniedCO18
Totals						$28,762.00	$15,819.10	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-751467
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-05-18 to 2026-05-21
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-024328 (verified, link confidence 0.88).
Eligibility	Pass		Active on 2026-05-18: NAVIGATE-HMO (HMO), effective 2021-07-01.
Timely filing	Pass		Received 44 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-009673: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2026219304 on file for 27447.
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	Review	HIGH	Billed $28,762.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Orthopedic Specialists2026-05-20 15:11
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-07-03 06:52
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-03 16:36
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026219304_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-05-18 to 2026-08-16.
Itemized billitemized_PA-751467.pdf6 pages
Itemised statement totalling $28762.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-009673: same member, date of service, procedures and billing provider. High-dollar review: Billed $28,762.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023329	2026-07-15	Summit Counseling Center	$334.00	Needs review
CLM-2026-009673	2026-05-18	Heritage Orthopedic Specialists	$28,762.00	Needs review
CLM-2026-017515	2026-03-20	Meadow Primary Care Associates	$253.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity