CLM-2026-010774
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-02-27 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Ann Kelley
- Member ID
- UHC-38082-71
- Date of birth
- 1967-01-18
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-409626
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3329
- Coverage period
- 2024-02-01 to present
- Deductible
- $57.05 of $500.0011%
- Out-of-pocket maximum
- $365.22 of $1,500.0024%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 8335878780
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- none / REF960377
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $201.00 | $124.62 | — | — | Review |
| Totals | $201.00 | $124.62 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-842480
- 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-001660 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-27: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for other tear of medial meniscus, right knee, initial encounter. Note dictat”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Bone and Joint Center2026-02-27 12:59
Patient seen for other tear of medial meniscus, right knee, initial encounter. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-20 06:44
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-20 11:39
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for other tear of medial meniscus, right knee, initial encounter. Note dictat”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013653 | 2026-03-31 | Meadow Dermatology Clinic | $398.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.