CLM-2026-018133
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-03-26 at outpatient hospital (POS 22). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Willie Martin
- Member ID
- UHC-69388-74
- Date of birth
- 1953-11-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419483
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9130
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,026.77 of $2,500.0041%
- Out-of-pocket maximum
- $1,825.60 of $10,000.0018%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 4232209237
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2026231900 / 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 | $6,892.00 | $3,790.60 | $1,704.97 | $2,085.63 | Paid |
| Totals | $6,892.00 | $3,790.60 | $1,704.97 | $2,085.63 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-246154
- 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-000005 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-26: CHOICE-PLUS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026231900 on file for 29881. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-03-26 15:51
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026231900_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-26 to 2026-06-24.
- Itemized billitemized_PA-246154.pdf7 pages
Itemised statement totalling $6892.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025372 | 2026-09-18 | Heritage Medical Group | $323.00 | Approved |
| CLM-2026-029037 | 2025-12-26 | Desert Family Practice | $315.00 | Needs review |
| CLM-2026-029036 | 2025-12-26 | Desert Family Practice | $315.00 | Approved |
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.