CLM-2026-012218
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-02-15 to 2026-02-17 at inpatient hospital (POS 21). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Nicholas Gomez
- Member ID
- UHC-98466-97
- Date of birth
- 1984-01-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406021
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2024-12-01 to present
- Deductible
- $354.10 of $500.0071%
- Out-of-pocket maximum
- $11.02 of $1,500.001%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 5890605657
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2026767905 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $35,980.00 | $19,789.00 | — | — | Review |
| Totals | $35,980.00 | $19,789.00 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-219999
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-02-15 to 2026-02-17
- 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-015839 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-15: MEDICARE-ADV-B (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026767905 on file for 27447. | |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Review | HIGH | Billed $35,980.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Bone and Joint Center2026-02-17 10:56
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-02-25 00:39
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-25 14:51
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026767905_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-02-15 to 2026-05-16.
- Itemized billitemized_PA-219999.pdf8 pages
Itemised statement totalling $35980.00 across 1 line.
- Medical recordrecords_PA-219999.pdf8 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44High-dollar review: Billed $35,980.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
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
Above auto-pay ceiling; payable once an examiner signs off.