CLM-2026-019324
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-02 at outpatient hospital (POS 22). Received 2026-06-03.
Member
Resolved through the identity graph
- Member
- Walter Clark
- Member ID
- UHC-73064-35
- Date of birth
- 1980-03-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408871
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1798
- Coverage period
- 2024-11-01 to present
- Deductible
- $800.77 of $2,500.0032%
- Out-of-pocket maximum
- $2,258.36 of $7,500.0030%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 2156915326
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2026906897 / 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 | $1,678.00 | $922.90 | $922.90 | $0.00 | Paid |
| Totals | $1,678.00 | $922.90 | $922.90 | $0.00 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M25.561 Pain in right knee
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-960951
- 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-033381 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026906897 on file for 73721. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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: Pinecrest Bone and Joint Center2026-05-02 11:39
Patient seen for unilateral primary osteoarthritis, left knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026906897_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-02 to 2026-07-31.
- Itemized billitemized_PA-960951.pdf3 pages
Itemised statement totalling $1678.00 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-2026-028367 | 2026-08-25 | Mesa Regional Medical Center | $1,736.00 | Needs review |
| CLM-2026-019013 | 2026-08-03 | Riverside Regional Medical Center | $2,031.00 | Needs review |
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.