CLM-2026-015271
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-06-17 at outpatient hospital (POS 22). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Kathleen Fisher
- Member ID
- UHC-76265-13
- Date of birth
- 1940-06-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422956
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0660
- Coverage period
- 2024-11-01 to present
- Deductible
- $542.49 of $1,500.0036%
- Out-of-pocket maximum
- $995.66 of $4,500.0022%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 6700145595
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2025086839 / REF607920
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 | $9,217.00 | $5,069.35 | $2,191.06 | $2,878.29 | Paid |
| Totals | $9,217.00 | $5,069.35 | $2,191.06 | $2,878.29 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-125602
- 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-037361 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-17: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025086839 on file for 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (3990196263). | |
| 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 Center2026-06-17 14:26
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025086839_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-06-17 to 2026-09-15.
- Itemized billitemized_PA-125602.pdf6 pages
Itemised statement totalling $9217.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014990 | 2026-07-18 | Mesa Family Practice | $328.00 | Approved |
| CLM-2026-002269 | 2026-05-22 | Desert Medical Group | $480.00 | 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.