CLM-2026-020040
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-01-30 at outpatient hospital (POS 22). Received 2026-03-12.
Member
Resolved through the identity graph
- Member
- Donna Ramirez
- Member ID
- UHC-71663-58
- Date of birth
- 1978-07-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-425983
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8207
- Coverage period
- 2021-02-01 to 2026-02-02
- Deductible
- $3,091.76 of $3,500.0088%
- Out-of-pocket maximum
- $684.46 of $14,000.005%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 7015688287
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2025799993 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,372.00 | $5,704.60 | $937.88 | $4,766.72 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | 25 | 1 | 1 | $1,730.00 | $951.50 | $95.15 | $856.35 | Paid |
| Totals | $12,102.00 | $6,656.10 | $1,033.03 | $5,623.07 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-592929
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019220 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-30: MEDICARE-ADV-B (MA), effective 2021-02-01, terms 2026-02-02. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025799993 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-01-30 13:34
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025799993_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-30 to 2026-04-30.
- Itemized billitemized_PA-592929.pdf7 pages
Itemised statement totalling $12102.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032558 | 2026-04-30 | Northgate Counseling Center | $227.00 | Denied |
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.