Claims workbench/CLM-2026-018699

Institutional claim · UB-04 · EDI 837I

CLM-2026-018699

Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-03 to 2026-04-07 at inpatient hospital (POS 21). Received 2026-04-06.

PendedIdentity on hold: CASE-003386

Billed

$40,139.00

1 line

Allowed

$22,076.45

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jeffrey Aguilar
Member ID: none on golden record
Date of birth: 1966-01-25
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-414817
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-9111
Coverage period: 2021-04-01 to present
Deductible: $828.96 of $2,500.0033%
Out-of-pocket maximum: $1,538.76 of $5,000.0031%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 21 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3819335712
Network: In network
Rendering NPI: 9790766478
Location: Tampa, FL · TIN 32-1762387
Authorisation / referral: PA2026549028 / 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	$40,139.00	$22,076.45	—	—	PendedIDQ
Totals						$40,139.00	$22,076.45	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-495510
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-04-03 to 2026-04-06
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 4 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003386; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-04-03: CHOICE-PLUS-PPO (PPO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received -1 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026549028 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	Review	CO16	Documentation incomplete: “Patient seen for unilateral primary osteoarthritis, right knee. Note dictated; signature p”. Claim lacks information needed for adjudication
High-dollar review	Review	HIGH	Billed $40,139.00 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: Pended.

Notes

Provider, system and examiner notes on this claim

SystemSystem: Claims system2026-04-06 06:47
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-06 15:34
Reviewed with the member's history on file. Holding for the items listed above.
ClinicalProvider: Heritage Orthopedic Specialists2026-04-07 11:56
Patient seen for unilateral primary osteoarthritis, right knee. Note dictated; signature pending.

Attachments

Documents received with the claim

Prior auth letterPA2026549028_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-04-03 to 2026-07-02.
Itemized billitemized_PA-495510.pdf6 pages
Itemised statement totalling $40139.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-003386; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-03: CHOICE-PLUS-PPO (PPO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Patient seen for unilateral primary osteoarthritis, right knee. Note dictated; signature p”. High-dollar review: Billed $40,139.00 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

Record the final decision; pricing and remittance reasons follow from it

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity