CLM-2026-012816
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2025-12-26 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Ruth Pierce
- Member ID
- UHC-19964-20
- Date of birth
- 2002-09-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420220
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7654
- Coverage period
- 2022-07-01 to present
- Deductible
- $389.27 of $3,500.0011%
- Out-of-pocket maximum
- $3,398.81 of $7,000.0049%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 6944174815
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PHONE-282139 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $5,855.00 | $3,220.25 | — | — | Review |
| Totals | $5,855.00 | $3,220.25 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-893490
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000562 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-26: CHOICE-PLUS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-282139” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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: Harbor Bone and Joint Center2025-12-26 10:30
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-02 02:26
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-02 08:35
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-893490.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-893490.pdf9 pages
Itemised statement totalling $5855.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-282139” does not match the utilisation-management format; must be confirmed before payment.
- AI recommendationPended2026-10-21 14:05The claim has passed all deterministic rules checks except for the prior authorization, which does not match the utilisation-management format. The claim must be pended to confirm the prior authorization reference 'PHONE-282139' with the plan to ensure it matches the required format.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 489e9510
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033300 | 2026-08-18 | Sunrise Behavioral Health | $567.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO197 Precertification or authorization absent
The claim has passed all deterministic rules checks except for the prior authorization, which does not match the utilisation-management format. The claim must be pended to confirm the prior authorization reference 'PHONE-282139' with the plan to ensure it matches the required format.
- Verify the prior authorization reference 'PHONE-282139' with the plan to ensure it matches the utilisation-management format.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO197 Precertification or authorization absent
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.