CLM-2026-012857
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-13 at outpatient hospital (POS 22). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Susan Bishop
- Member ID
- UHC-19257-25
- Date of birth
- 1972-05-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417368
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1603
- Coverage period
- 2021-05-01 to present
- Deductible
- $342.87 of $500.0069%
- Out-of-pocket maximum
- $532.00 of $1,500.0035%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 1474381716
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2026964703 / 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 | $6,722.00 | $3,697.10 | $511.13 | $3,185.97 | Paid |
| Totals | $6,722.00 | $3,697.10 | $511.13 | $3,185.97 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-447023
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033182 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-13: NULL (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026964703 on file for 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (3990196263). | |
| 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: Pinecrest Bone and Joint Center2026-05-13 16:34
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026964703_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-13 to 2026-08-11.
- Itemized billitemized_PA-447023.pdf5 pages
Itemised statement totalling $6722.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.