CLM-2026-013852
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-03-19 at outpatient hospital (POS 22). Received 2026-04-22.
Member
Resolved through the identity graph
- Member
- Ethan Turner
- Member ID
- UHC-63512-82
- Date of birth
- 1979-07-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412762
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1641
- Coverage period
- 2022-02-01 to present
- Deductible
- $631.85 of $1,000.0063%
- Out-of-pocket maximum
- $526.26 of $3,000.0018%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 7965070189
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- PA2026920608 / REF570597
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 | $8,540.00 | $4,697.00 | $801.04 | $3,895.96 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,362.00 | $1,299.10 | $129.91 | $1,169.19 | Paid |
| Totals | $10,902.00 | $5,996.10 | $930.95 | $5,065.15 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-856265
- 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-016328 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-19: CORE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026920608 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Sunrise Bone and Joint Center (8496214718). | |
| 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: Sunrise Bone and Joint Center2026-03-19 11:31
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026920608_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-19 to 2026-06-17.
- Itemized billitemized_PA-856265.pdf8 pages
Itemised statement totalling $10902.00 across 2 lines.
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.