CLM-2026-020070
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-07-19 at outpatient hospital (POS 22). Received 2026-07-24.
Member
Resolved through the identity graph
- Member
- Anthony Ortiz
- Member ID
- UHC-26515-31
- Date of birth
- 1962-11-28
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431794
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4425
- Coverage period
- 2021-06-01 to present
- Deductible
- $390.53 of $1,000.0039%
- Out-of-pocket maximum
- $1,204.55 of $3,000.0040%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 2569233937
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2026115469 / REF799419
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 | $9,246.00 | $5,085.30 | $1,057.05 | $4,028.25 | Paid |
| Totals | $9,246.00 | $5,085.30 | $1,057.05 | $4,028.25 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-268055
- 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-030401 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-19: CORE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026115469 on file for 29881. | |
| 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 Center2026-07-19 18:22
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026115469_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-07-19 to 2026-10-17.
- Itemized billitemized_PA-268055.pdf6 pages
Itemised statement totalling $9246.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030462 | 2026-04-12 | Mesa Internal Medicine Associates | $253.00 | Denied |
| CLM-2026-030461 | 2026-04-12 | Canyon Medical Group | $253.00 | 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.