CLM-2026-011412
Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-18 at outpatient hospital (POS 22). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Richard Cruz
- Member ID
- UHC-30512-30
- Date of birth
- 2008-02-16
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425295
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-5026
- Coverage period
- 2022-02-01 to 2026-04-17
- Deductible
- $244.66 of $1,500.0016%
- Out-of-pocket maximum
- $113.75 of $3,000.004%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3819335712
- Network
- In network
- Rendering NPI
- 2461846398
- Location
- Tampa, FL · TIN 32-1762387
- Authorisation / referral
- PA2026564066 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,326.00 | $729.30 | — | — | DeniedCO27 |
| Totals | $1,326.00 | $729.30 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-324993
- 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-027286 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-18 is after coverage terminated on 2026-04-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026564066 on file for 73721. | |
| Provider network | Pass | In-network provider Heritage Orthopedic Specialists (3819335712). | |
| 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: Heritage Orthopedic Specialists2026-08-18 09:46
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-19 04:41
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-19 12:36
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026564066_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-08-18 to 2026-11-16.
- Itemized billitemized_PA-324993.pdf7 pages
Itemised statement totalling $1326.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-18 is after coverage terminated on 2026-04-17.
Other claims for this member
Same resolved identity
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.