CLM-2026-012361
Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-13 to 2026-03-17 at inpatient hospital (POS 21). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Nicole Sndyer
- Member ID
- UHC-92703-71
- Date of birth
- 1949-01-09
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-406205
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3969
- Coverage period
- 2023-02-01 to present
- Deductible
- $265.90 of $500.0053%
- Out-of-pocket maximum
- $926.99 of $2,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3819335712
- Network
- In network
- Rendering NPI
- 4797761283
- Location
- Tampa, FL · TIN 32-1762387
- Authorisation / referral
- none / 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 | $37,369.00 | $20,552.95 | — | — | DeniedCO197 |
| Totals | $37,369.00 | $20,552.95 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-684809
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-03-13 to 2026-03-17
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024109 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-13: OPTIONS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 19 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 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 | Review | HIGH | Billed $37,369.00 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: Heritage Orthopedic Specialists2026-03-17 16:35
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-05 06:34
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-684809.pdf2 pages
Itemised statement totalling $37369.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $37,369.00 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-2026-007087 | 2026-04-14 | Desert Reference Lab | $96.00 | Approved |
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
Precertification required and absent.