CLM-2026-018857
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-05-12 at outpatient hospital (POS 22). Received 2026-08-19.
Member
Resolved through the identity graph
- Member
- Linda Munoz
- Member ID
- UHC-59937-01
- Date of birth
- 1988-01-13
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-408179
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8308
- Coverage period
- 2025-07-01 to present
- Deductible
- $44.25 of $1,000.004%
- Out-of-pocket maximum
- $308.49 of $4,000.008%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 4829390267
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2026422306 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,335.00 | $600.75 | — | — | DeniedCO29 |
| Totals | $1,335.00 | $600.75 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-382482
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-042003 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-12: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Fail | CO29 | Received 99 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 PA2026422306 on file for 73721. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Bone and Joint Center2026-05-12 17:34
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-19 03:03
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026422306_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-12 to 2026-08-10.
- Itemized billitemized_PA-382482.pdf3 pages
Itemised statement totalling $1335.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 99 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Received after the timely-filing limit.