CLM-2026-020627
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-07 to 2026-01-08 at inpatient hospital (POS 21). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Janet Chaapman
- Member ID
- UHC-78660-10
- Date of birth
- 1979-08-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423620
- Relationship
- Child
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9206
- Coverage period
- 2021-05-01 to present
- Deductible
- $812.19 of $3,500.0023%
- Out-of-pocket maximum
- $3,843.43 of $14,000.0027%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 9804332945
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- PA2026986239 / 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 | $30,241.00 | $16,632.55 | — | — | Review |
| Totals | $30,241.00 | $16,632.55 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-354993
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-01-07 to 2026-01-09
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005043 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-07: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026986239 on file for 27447. | |
| 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 | Review | HIGH | Billed $30,241.00 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: Sunrise Orthopedic Specialists2026-01-08 10:20
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-16 01:38
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-16 14:19
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026986239_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-01-07 to 2026-04-07.
- Itemized billitemized_PA-354993.pdf3 pages
Itemised statement totalling $30241.00 across 1 line.
- Medical recordrecords_PA-354993.pdf9 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44High-dollar review: Billed $30,241.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-23 19:14The claim for total knee arthroplasty is supported by the prior authorization [A1], the clinical note [N1], and the medical record [A3]. The provider is in-network [R-network], and the member is eligible [R-eligibility]. Although the billed amount exceeds the auto-adjudication ceiling [N2], the documentation is complete [R-completeness], and the service is medically necessary [R-clinical_edit]. The claim is approved pending examiner sign-off due to the high-dollar amount.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:14 · 94f8b141
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for total knee arthroplasty is supported by the prior authorization [A1], the clinical note [N1], and the medical record [A3]. The provider is in-network [R-network], and the member is eligible [R-eligibility]. Although the billed amount exceeds the auto-adjudication ceiling [N2], the documentation is complete [R-completeness], and the service is medically necessary [R-clinical_edit]. The claim is approved pending examiner sign-off due to the high-dollar amount.
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
Above auto-pay ceiling; payable once an examiner signs off.