CLM-2026-009776
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2025-11-25 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Santiago Franklin
- Member ID
- UHC-35421-78
- Date of birth
- 1954-10-10
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-424554
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8874
- Coverage period
- 2022-02-01 to present
- Deductible
- $2,444.29 of $3,500.0070%
- Out-of-pocket maximum
- $1,275.68 of $10,500.0012%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 8060999892
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- PA2026835034 / 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 | $1,374.00 | $755.70 | $755.70 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,776.00 | $5,926.80 | $1,425.37 | $4,501.43 | Paid |
| Totals | $12,150.00 | $6,682.50 | $2,181.07 | $4,501.43 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-213680
- 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-002328 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-11-25: MEDICARE-ADV-A (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026835034 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Sunrise Bone and Joint Center (8496214718). | |
| 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 Bone and Joint Center2025-11-25 14:22
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026835034_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-11-25 to 2026-02-23.
- Itemized billitemized_PA-213680.pdf7 pages
Itemised statement totalling $12150.00 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.