CLM-2026-015327
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-06 at office (POS 11). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Rebecca Howard
- Member ID
- UHC-89882-71
- Date of birth
- 1998-06-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432429
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7949
- Coverage period
- 2022-04-01 to 2026-01-11
- Deductible
- $2,213.91 of $3,500.0063%
- Out-of-pocket maximum
- $3,218.77 of $7,000.0046%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 5432720154
- Location
- Phoenix, AZ · TIN 14-5056475
- 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 | $198.00 | $122.76 | — | — | DeniedCO27 |
| 2 | 20610 | Joint injection, major joint | 25 | 1 | 1 | $281.00 | $174.22 | — | — | DeniedCO27 |
| Totals | $479.00 | $296.98 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-900663
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021909 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-06 is after coverage terminated on 2026-01-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 Orthopedic Specialists (2414063810). | |
| 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: Sunrise Orthopedic Specialists2026-05-06 17:35
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-17 00:54
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-17 09:01
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-06 is after coverage terminated on 2026-01-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032499 | 2026-09-04 | Sunrise Counseling Center | $484.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.