CLM-2026-010004
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-09-06 at outpatient hospital (POS 22). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Diego Valdez
- Member ID
- UHC-00431-81
- Date of birth
- 1962-04-06
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-402880
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1473
- Coverage period
- 2025-06-01 to present
- Deductible
- $357.38 of $1,000.0036%
- Out-of-pocket maximum
- $1,016.23 of $4,000.0025%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 7730789543
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2026846652 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,636.00 | $4,749.80 | $1,464.06 | $3,285.74 | Paid |
| Totals | $8,636.00 | $4,749.80 | $1,464.06 | $3,285.74 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-386393
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026803 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-06: CHOICE-PLUS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026846652 on file for 29881. | |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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: Harbor Bone and Joint Center2026-09-06 12:23
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026846652_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-09-06 to 2026-12-05.
- Itemized billitemized_PA-386393.pdf7 pages
Itemised statement totalling $8636.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.