CLM-2026-015068
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-06-01 to 2026-06-05 at inpatient hospital (POS 21). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Carl Kennedy
- Member ID
- UHC-27655-75
- Date of birth
- 1947-07-22
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-405288
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9665
- Coverage period
- 2024-05-01 to present
- Deductible
- $410.55 of $500.0082%
- Out-of-pocket maximum
- $265.27 of $1,000.0027%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 3441811858
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PHONE-742720 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $47,617.00 | $26,189.35 | — | — | Review |
| Totals | $47,617.00 | $26,189.35 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-473118
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-06-01 to 2026-06-03
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001723 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-01: MEDICARE-ADV-A (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-742720” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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 | Review | HIGH | Billed $47,617.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Bone and Joint Center2026-06-05 17:10
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-29 01:26
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-29 14:46
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-473118.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-473118.pdf6 pages
Itemised statement totalling $47617.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-742720” does not match the utilisation-management format; must be confirmed before payment. High-dollar review: Billed $47,617.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.