CLM-2026-012950
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-01-05 at outpatient hospital (POS 22). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Teresa Payne
- Member ID
- UHC-81632-20
- Date of birth
- 1959-09-23
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-410916
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9980
- Coverage period
- 2022-05-01 to present
- Deductible
- $456.25 of $2,500.0018%
- Out-of-pocket maximum
- $803.32 of $5,000.0016%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 2719238810
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2026511715 / 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 | $10,383.00 | $5,710.65 | — | — | Review |
| Totals | $10,383.00 | $5,710.65 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-153329
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-005314 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-05: NULL (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026511715 on file for 29881. | |
| 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 | Review | CO16 | Documentation incomplete: “Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; s”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Bone and Joint Center2026-01-05 12:08
Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-17 03:47
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-17 17:49
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026511715_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-05 to 2026-04-05.
- Itemized billitemized_PA-153329.pdf9 pages
Itemised statement totalling $10383.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; s”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004877 | 2025-12-19 | Mesa Cardiovascular Associates | $10,035.00 | Approved |
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
Development letter outstanding.