Claims workbench/CLM-2026-011367

Institutional claim · UB-04 · EDI 837I

CLM-2026-011367

Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-09-11 to 2026-09-14 at inpatient hospital (POS 21). Received 2026-09-18.

Denied

Billed

$36,345.00

1 line

Allowed

$19,989.75

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Martha Henderson
Member ID: UHC-24638-57
Date of birth: 2008-10-26
Identity: Verified6 records, confidence 0.94
Claim record: CLMCLM-417251
Relationship: Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-1628
Coverage period: 2025-06-01 to present
Deductible: $2,548.72 of $3,500.0073%
Out-of-pocket maximum: $2,563.41 of $10,500.0024%
Copays: office $25.00, specialist $60.00, emergency $150.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 8824040173
Network: In network
Rendering NPI: 9305925981
Location: Scottsdale, AZ · TIN 78-6151009
Authorisation / referral: none / REF213220

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	27447 rev 0360	Total knee arthroplasty	—	1	1	$36,345.00	$19,989.75	—	—	DeniedCO197
Totals						$36,345.00	$19,989.75	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter

Claim header

Patient account: PA-808654
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-09-11 to 2026-09-15
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-006956 (verified, link confidence 0.94).
Eligibility	Pass		Active on 2026-09-11: NAVIGATE-HMO (HMO), effective 2025-06-01.
Timely filing	Pass		Received 4 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	27447 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Pinecrest Bone and Joint Center (8824040173).
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	Review	HIGH	Billed $36,345.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Bone and Joint Center2026-09-14 18:46
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-09-18 04:50
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-18 13:23
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Itemized billitemized_PA-808654.pdf5 pages
Itemised statement totalling $36345.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $36,345.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-029576	2026-08-29	Harbor Medical Group	$238.00	Approved
CLM-2026-003285	2026-05-19	Sunrise Medical Group	$397.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity