Claims workbench/CLM-2026-021084

Institutional claim · UB-04 · EDI 837I

CLM-2026-021084

Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-08-13 at outpatient hospital (POS 22). Received 2026-09-26.

Denied

Billed

$9,739.00

1 line

Allowed

$5,356.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Judy Burns
Member ID: UHC-13174-98
Date of birth: 1980-12-09
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-415697
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-1473
Coverage period: 2021-06-01 to 2026-03-17
Deductible: $236.20 of $1,000.0024%
Out-of-pocket maximum: $286.51 of $3,000.0010%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 2148364427
Network: In network
Rendering NPI: 3114479868
Location: Tampa, FL · TIN 14-7269323
Authorisation / referral: PA2025277366 / 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	$9,739.00	$5,356.45	—	—	DeniedCO27
Totals						$9,739.00	$5,356.45	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal

Claim header

Patient account: PA-868171
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
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-007661 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-08-13 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated
Timely filing	Pass		Received 44 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025277366 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.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Bone and Joint Center2026-08-13 14:41
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-09-26 03:00
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-26 14:25
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025277366_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-13 to 2026-11-11.
Itemized billitemized_PA-868171.pdf9 pages
Itemised statement totalling $9739.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-08-13 is after coverage terminated on 2026-03-17.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-031335	2026-08-08	Meadow Bone and Joint Center	$236.00	Denied
CLM-2026-018266	2026-03-23	Sunrise Physical Therapy	$538.00	Denied
CLM-2026-032125	2025-12-31	Lakeside Digestive Health Center	$1,758.00	Approved
CLM-2026-010350	2026-01-21	Mesa Clinical Laboratories	$174.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity