CLM-2026-014352
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-01-04 at office (POS 11). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Margaret Cole
- Member ID
- UHC-65282-20
- Date of birth
- 1973-09-02
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416641
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4072
- Coverage period
- 2025-09-01 to present
- Deductible
- $427.02 of $1,500.0028%
- Out-of-pocket maximum
- $297.37 of $4,500.007%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 5919848619
- Location
- Scottsdale, AZ · TIN 78-6151009
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $232.00 | $143.84 | $60.00 | $83.84 | Paid |
| Totals | $232.00 | $143.84 | $60.00 | $83.84 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-673197
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001759 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-04: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 2 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 (8824040173). | |
| 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 Center2026-01-04 09:38
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014353 | 2026-01-04 | Sunrise Orthopedic Specialists | $232.00 | Needs review |
| CLM-2026-016789 | 2025-12-02 | Pinecrest Regional Medical Center | $2,227.00 | Approved |
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.