CLM-2026-015920
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-01-21 to 2026-01-22 at inpatient hospital (POS 21). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Debra Holmes
- Member ID
- UHC-55286-16
- Date of birth
- 2003-01-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421723
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9578
- Coverage period
- 2023-09-01 to present
- Deductible
- $196.11 of $1,500.0013%
- Out-of-pocket maximum
- $330.60 of $4,500.007%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 4647231404
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- none / 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 | $44,175.00 | $24,296.25 | — | — | DeniedCO197 |
| Totals | $44,175.00 | $24,296.25 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-646594
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-01-21 to 2026-01-22
- 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-000223 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-21: SELECT-EPO (EPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 27447 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 | Review | HIGH | Billed $44,175.00 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: Pinecrest Bone and Joint Center2026-01-22 14:26
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-16 01:02
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-16 11:03
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-646594.pdf6 pages
Itemised statement totalling $44175.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $44,175.00 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
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.