Claims workbench/CLM-2026-018578

Institutional claim · UB-04 · EDI 837I

CLM-2026-018578

Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-11 to 2026-04-12 at inpatient hospital (POS 21). Received 2026-08-02.

Denied

Billed

$49,532.00

1 line

Allowed

$27,242.60

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Keith Rojas
Member ID: UHC-26687-74
Date of birth: 1989-12-26
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-419790
Relationship: Spouse, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-3585
Coverage period: 2021-09-01 to present
Deductible: $1,616.85 of $2,500.0065%
Out-of-pocket maximum: $4,837.34 of $10,000.0048%
Copays: office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits: 2 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3819335712
Network: In network
Rendering NPI: 3968675280
Location: Tampa, FL · TIN 32-1762387
Authorisation / referral: PA2025290499 / 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	$49,532.00	$27,242.60	—	—	DeniedCO29
Totals						$49,532.00	$27,242.60	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
2. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-746528
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-04-11 to 2026-04-13
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-040401 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-04-11: MEDICARE-ADV-B (MA), effective 2021-09-01.
Timely filing	Fail	CO29	Received 112 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025290499 on file for 27447.
Provider network	Pass		In-network provider Heritage Orthopedic Specialists (3819335712).
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 $49,532.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Orthopedic Specialists2026-04-12 14:01
Patient seen for unilateral primary osteoarthritis, left knee.
SystemSystem: Claims system2026-08-02 00:31
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-02 13:56
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2025290499_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-04-11 to 2026-07-10.
Itemized billitemized_PA-746528.pdf3 pages
Itemised statement totalling $49532.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 112 days after the last date of service (limit 90). High-dollar review: Billed $49,532.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity