CLM-2026-016245
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-31 at office (POS 11). Received 2026-07-11.
Member
Resolved through the identity graph
- Member
- Amber Wells
- Member ID
- UHC-31236-97
- Date of birth
- 1979-06-25
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-400070
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-9279
- Coverage period
- 2025-03-01 to present
- Deductible
- $514.50 of $1,000.0051%
- Out-of-pocket maximum
- $1,380.46 of $4,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 4892503242
- Location
- Tampa, FL · TIN 14-7269323
- 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 | $163.00 | $101.06 | — | — | DeniedCO18 |
| Totals | $163.00 | $101.06 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-758827
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032224 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-31: N/A (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016244: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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 Center2026-05-31 16:55
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-11 06:21
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-016244: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006700 | 2026-09-11 | Riverside Digestive Health Center | $2,351.00 | Approved |
| CLM-2026-016244 | 2026-05-31 | Pinecrest Bone and Joint Center | $163.00 | Approved |
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
Exact duplicate of an earlier submission.