CLM-2026-016962
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-06-17 at outpatient hospital (POS 22). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Emma Tucker
- Member ID
- UHC-67045-13
- Date of birth
- 1955-10-18
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-407112
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3780
- Coverage period
- 2021-08-01 to present
- Deductible
- $621.09 of $1,500.0041%
- Out-of-pocket maximum
- $135.41 of $3,000.005%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 2842961478
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PHONE-987239 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,824.00 | $5,953.20 | — | — | Review |
| Totals | $10,824.00 | $5,953.20 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-102308
- 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-001793 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-17: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-987239” does not match the utilisation-management format; must be confirmed before payment. 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-06-17 15:34
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-07 05:43
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-102308.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-102308.pdf3 pages
Itemised statement totalling $10824.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-987239” does not match the utilisation-management format; must be confirmed before payment.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.