CLM-2026-017291
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-03-06 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Omar Myers
- Member ID
- UHC-56404-63
- Date of birth
- 1958-06-01
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-420519
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5414
- Coverage period
- 2021-07-01 to 2026-01-27
- Deductible
- $318.61 of $3,500.009%
- Out-of-pocket maximum
- $932.75 of $14,000.007%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 9022777632
- Location
- Tampa, FL · TIN 23-8846705
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $314.00 | $194.68 | — | — | DeniedCO27 |
| Totals | $314.00 | $194.68 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-389453
- 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-011053 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-06 is after coverage terminated on 2026-01-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 Harbor Bone and Joint Center (1970418400). | |
| 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: Harbor Bone and Joint Center2026-03-06 16:45
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-16 00:12
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-16 12:39
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-06 is after coverage terminated on 2026-01-27.
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
Service after coverage termination.