CLM-2026-013381
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-02-12 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Santiago Obrien
- Member ID
- UHC-24963-18
- Date of birth
- 1991-08-09
- Identity
- Verified5 records, confidence 0.98
- Claim record
- CLMCLM-419824
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group -
- Coverage period
- 2021-04-01 to present
- Deductible
- $101.26 of $1,000.0010%
- Out-of-pocket maximum
- $1,803.27 of $4,000.0045%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 8931387608
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $294.00 | $182.28 | — | — | Review |
| Totals | $294.00 | $182.28 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-328521
- 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-003041 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-02-12: NULL (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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: Pinecrest Bone and Joint Center2026-02-12 16:18
Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-20 02:32
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
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-2026-020086 | 2025-12-05 | Mesa Bone and Joint Center | $9,845.00 | 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.