CLM-2026-013643
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-04-24 at outpatient hospital (POS 22). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Mark Roberts
- Member ID
- UHC-20647-47
- Date of birth
- 1955-12-08
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-406378
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0954
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,478.62 of $3,500.0042%
- Out-of-pocket maximum
- $1,569.86 of $10,500.0015%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 9293774417
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- none / 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 | $1,551.00 | $853.05 | — | — | DeniedCO197 |
| Totals | $1,551.00 | $853.05 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-327673
- 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-012787 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-24: MEDICARE-ADV-A (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-04-24 14:25
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-05-15 00:14
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-327673.pdf8 pages
Itemised statement totalling $1551.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026683 | 2026-08-21 | Evergreen Cardiovascular Associates | $5,574.00 | Approved |
| CLM-2026-004979 | 2026-01-16 | Canyon Primary Care Associates | $338.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.