CLM-2026-019199
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-08 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Harold Allen
- Member ID
- UHC-32188-32
- Date of birth
- 1982-05-24
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-414024
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3538
- Coverage period
- 2025-08-01 to present
- Deductible
- $253.10 of $3,500.007%
- Out-of-pocket maximum
- $3,084.31 of $14,000.0022%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 7906513842
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- PA2025885605 / 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 | $2,014.00 | $1,107.70 | $1,107.70 | $0.00 | Paid |
| Totals | $2,014.00 | $1,107.70 | $1,107.70 | $0.00 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M25.561 Pain in right knee
- Patient account
- PA-262918
- 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-003695 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-08: - (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025885605 on file for 73721. | |
| Provider network | Pass | In-network provider Sunrise Orthopedic Specialists (2414063810). | |
| 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: Sunrise Orthopedic Specialists2026-09-08 17:32
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025885605_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-08 to 2026-12-07.
- Itemized billitemized_PA-262918.pdf8 pages
Itemised statement totalling $2014.00 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-2026-013784 | 2026-09-14 | Northgate Medical Group | $231.00 | 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.