CLM-2026-014850
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-02-06 at outpatient hospital (POS 22). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Beverly Howell
- Member ID
- UHC-53616-93
- Date of birth
- 1988-10-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429377
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9887
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,858.54 of $2,500.0074%
- Out-of-pocket maximum
- $834.87 of $10,000.008%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 3821263936
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2026367634 / 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 | $1,856.00 | $835.20 | $699.58 | $135.62 | Paid |
| Totals | $1,856.00 | $835.20 | $699.58 | $135.62 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-360823
- 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-007558 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-06: CHOICE-PLUS-PPO (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026367634 on file for 73721. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Bone and Joint Center2026-02-06 10:23
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026367634_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-02-06 to 2026-05-07.
- Itemized billitemized_PA-360823.pdf3 pages
Itemised statement totalling $1856.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009086 | 2025-12-17 | Desert Primary Care Associates | $394.00 | Needs review |
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.