CLM-2026-011008
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-30 at office (POS 11). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Keith Watson
- Member ID
- UHC-99757-95
- Date of birth
- 1991-02-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426815
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3210
- Coverage period
- 2021-01-01 to 2026-02-22
- Deductible
- $889.85 of $2,500.0036%
- Out-of-pocket maximum
- $2,340.57 of $5,000.0047%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 2780628824
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- none / none
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 | 20610 | Joint injection, major joint | — | 1 | 1 | $282.00 | $174.84 | — | — | DeniedCO27 |
| Totals | $282.00 | $174.84 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-849892
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021456 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-30 is after coverage terminated on 2026-02-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 Sunrise Orthopedic Specialists (2414063810). | |
| 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 Orthopedic Specialists2026-03-30 11:21
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-14 05:46
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-14 17:26
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-30 is after coverage terminated on 2026-02-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018934 | 2026-03-15 | Cornerstone Internal Medicine Associates | $463.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.