CLM-2026-019797
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-03-27 to 2026-03-28 at inpatient hospital (POS 21). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Paul Lopez
- Member ID
- UHC-40853-63
- Date of birth
- 1966-05-01
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-401860
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2625
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,187.01 of $1,500.0079%
- Out-of-pocket maximum
- $1,733.37 of $4,500.0039%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 7442139920
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2025409534 / 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 | $42,813.00 | $23,547.15 | — | — | Review |
| Totals | $42,813.00 | $23,547.15 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-111033
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-03-27 to 2026-03-28
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016509 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-27: OPTIONS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025409534 on file for 27447. | |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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 $42,813.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Bone and Joint Center2026-03-28 11:28
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025409534_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-03-27 to 2026-06-25.
- Itemized billitemized_PA-111033.pdf4 pages
Itemised statement totalling $42813.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $42,813.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019798 | 2026-03-27 | Harbor Bone and Joint Center | $42,813.00 | Denied |
| CLM-2026-006147 | 2026-01-14 | Heritage Clinical Laboratories | $76.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.