CLM-2026-020886
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-06-22 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Hannah Alvarado
- Member ID
- UHC-21773-81
- Date of birth
- 2001-11-22
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-406936
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5299
- Coverage period
- 2023-02-01 to present
- Deductible
- $640.81 of $2,500.0026%
- Out-of-pocket maximum
- $1,610.23 of $7,500.0021%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 3757538905
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2025514452 / 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 | $1,706.00 | $938.30 | $938.30 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 2 | $7,008.00 | $3,854.40 | $1,214.24 | $2,640.16 | Paid |
| Totals | $8,714.00 | $4,792.70 | $2,152.54 | $2,640.16 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-116853
- 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-000789 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-22: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025514452 on file for 73721, 29881. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Bone and Joint Center2026-06-22 11:37
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025514452_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-06-22 to 2026-09-20.
- Itemized billitemized_PA-116853.pdf9 pages
Itemised statement totalling $8714.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012183 | 2025-12-13 | Meadow Cardiovascular Associates | $1,461.00 | Needs review |
| CLM-2026-012182 | 2025-12-13 | Summit Cardiovascular Associates | $1,461.00 | 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.