CLM-2026-010963
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-23 at outpatient hospital (POS 22). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Ray Scott
- Member ID
- UHC-74464-51
- Date of birth
- 1988-07-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-402119
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6057
- Coverage period
- 2024-10-01 to present
- Deductible
- $632.28 of $1,500.0042%
- Out-of-pocket maximum
- $1,004.63 of $4,500.0022%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 9662618187
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2025551124 / 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 | $10,059.00 | $5,532.45 | $1,334.19 | $4,198.26 | Paid |
| Totals | $10,059.00 | $5,532.45 | $1,334.19 | $4,198.26 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-553016
- 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-012286 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: MEDICARE-ADV-A (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025551124 on file for 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 Center2026-05-23 13:45
Patient seen for unilateral primary osteoarthritis, left knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025551124_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-23 to 2026-08-21.
- Itemized billitemized_PA-553016.pdf3 pages
Itemised statement totalling $10059.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010938 | 2026-03-17 | Sunrise Diabetes Center | $634.00 | Needs review |
| CLM-2026-020120 | 2026-02-04 | Sunrise Medical Group | $238.00 | Needs review |
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.