CLM-2026-015653
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-03-05 at outpatient hospital (POS 22). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Katherine Hernandez
- Member ID
- UHC-76710-68
- Date of birth
- 1940-11-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-407113
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8173
- Coverage period
- 2024-02-01 to present
- Deductible
- $2,767.07 of $3,500.0079%
- Out-of-pocket maximum
- $729.90 of $10,500.007%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1938450750
- Network
- In network
- Rendering NPI
- 2443007424
- Location
- Mesa, AZ · TIN 27-3094451
- Authorisation / referral
- PA2025111796 / 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 | $1,324.00 | $728.20 | $728.20 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 2 | $8,020.00 | $4,411.00 | $445.36 | $3,965.64 | Paid |
| Totals | $9,344.00 | $5,139.20 | $1,173.56 | $3,965.64 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-853088
- 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-020169 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-05: NULL (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025111796 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (1938450750). | |
| 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 Center2026-03-05 18:25
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025111796_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-05 to 2026-06-03.
- Itemized billitemized_PA-853088.pdf9 pages
Itemised statement totalling $9344.00 across 2 lines.
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
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.