Claims workbench/CLM-2026-015273

Professional claim · CMS-1500 · EDI 837P

CLM-2026-015273

Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-06-07 at office (POS 11). Received 2026-07-09.

Approved

Billed

$425.00

2 lines

Allowed

$263.50

contract rate applied

Plan pays

$213.50

approved

Member owes

$50.00

copay / deductible / 20% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Nicole Gonzalez
Member ID: UHC-37073-66
Date of birth: 1959-04-24
Identity: Verified6 records, confidence 1.00
Claim record: CLMCLM-424096
Relationship: Child, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-5866
Coverage period: 2022-05-01 to present
Deductible: $235.82 of $500.0047%
Out-of-pocket maximum: $352.34 of $1,000.0035%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 8496214718
Network: In network
Rendering NPI: 5537066974
Location: Nashville, TN · TIN 33-7590536
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	20610	Joint injection, major joint	—	1	1	$219.00	$135.78	$50.00	$85.78	Paid
2	99213	Office visit, established patient, low complexity	—	1	2	$206.00	$127.72	$0.00	$127.72	Paid
Totals						$425.00	$263.50	$50.00	$213.50

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M25.561 Pain in right knee
3. M17.11 Unilateral primary osteoarthritis, right knee

Claim header

Patient account: PA-298091
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	Detail
Member identity	Pass	Attached to MBR-003217 (verified, link confidence 1.00).
Eligibility	Pass	Active on 2026-06-07: MEDICARE-ADV-A (MA), effective 2022-05-01.
Timely filing	Pass	Received 32 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 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.

Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Bone and Joint Center2026-06-07 17:06
Follow-up for low back pain, unspecified. 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 system2026-07-09 02:46
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-09 13:30
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-298091.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.

Explanation of benefits

What the member will see

Amount billed

$425.00

Plan discount

$161.50

contracted rate

Plan paid

$213.50

You may owe

$50.00

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

Rules engineApproved2026-10-21 13:43
Clean claim.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-008300	2026-09-10	Lakeside Skin Care Associates	$1,932.00	Needs review
CLM-2026-010736	2026-05-26	Sunrise Digestive Health Center	$2,367.00	Approved
CLM-2026-032577	2026-01-01	Lakeside Behavioral Health	$290.00	Denied
CLM-2026-032576	2026-01-01	Lakeside Behavioral Health	$290.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity