Claims workbench/CLM-2026-012490

Institutional claim · UB-04 · EDI 837I

CLM-2026-012490

Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-12.

Needs reviewOut of network

Billed

$1,976.00

1 line

Allowed

$889.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Kyle Kennedy
Member ID: UHC-54040-20
Date of birth: 2000-01-04
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-415380
Relationship: Self, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-9337
Coverage period: 2022-06-01 to present
Deductible: $837.85 of $1,000.0084%
Out-of-pocket maximum: $1,721.52 of $4,000.0043%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Valley Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 9793653152
Network: Out of network
Rendering NPI: 1919094791
Location: Mesa, AZ · TIN 68-9887889
Authorisation / referral: PA2026291713 / 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	$1,976.00	$889.20	—	—	Review
Totals						$1,976.00	$889.20	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-915577
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
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-000132 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-29: OPTIONS-PPO (PPO), effective 2022-06-01.
Timely filing	Pass		Received 14 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-012489, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2026291713 on file for 73721.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Bone and Joint Center2025-12-29 10:54
Patient seen for other tear of medial meniscus, right knee, initial encounter. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-01-12 03:39
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-12 14:17
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2026291713_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-12-29 to 2026-03-29.
Itemized billitemized_PA-915577.pdf3 pages
Itemised statement totalling $1976.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-012489, billed by a different provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005801	2026-06-15	Desert Medical Group	$77.00	Approved
CLM-2026-033530	2026-03-25	Sunrise Digestive Health Center	$2,490.00	Approved
CLM-2026-012489	2025-12-29	Pinecrest Bone and Joint Center	$1,976.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity