Claims workbench/CLM-2026-013732

Professional claim · CMS-1500 · Paper

CLM-2026-013732

Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-08-04 at office (POS 11). Received 2026-08-18.

Needs review

Billed

$259.00

1 line

Allowed

$160.58

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Patrick Sanders
Member ID: UHC-58486-46
Date of birth: 2005-09-06
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-429944
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-8425
Coverage period: 2023-01-01 to present
Deductible: $662.51 of $1,500.0044%
Out-of-pocket maximum: $1,182.65 of $4,500.0026%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 2148364427
Network: In network
Rendering NPI: 7439781676
Location: Tampa, FL · TIN 14-7269323
Authorisation / referral: none / REF638891

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	$259.00	$160.58	—	—	Review
Totals						$259.00	$160.58	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
2. M54.50 Low back pain, unspecified
3. M25.561 Pain in right knee

Claim header

Patient account: PA-472892
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-008595 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-04: CORE-HMO (HMO), effective 2023-01-01.
Timely filing	Pass		Received 14 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 unilateral primary osteoarthritis, left knee. Plan discussed, medications re”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Bone and Joint Center2026-08-04 18:13
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-08-18 02:11
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-18 15:38
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications re”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-013960	2026-10-07	Canyon Skin Care Associates	$650.00	Denied
CLM-2026-013959	2026-10-07	Canyon Skin Care Associates	$650.00	Approved
CLM-2026-013863	2026-06-15	Canyon Skin Care Associates	$782.00	Approved
CLM-2026-010768	2025-12-22	Mesa Dermatology Clinic	$1,087.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity