CLM-2026-021316
Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-09-15 at outpatient hospital (POS 22). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Scott Santos
- Member ID
- UHC-17213-41
- Date of birth
- 1961-03-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407879
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7926
- Coverage period
- 2021-02-01 to present
- Deductible
- $470.49 of $1,500.0031%
- Out-of-pocket maximum
- $389.98 of $6,000.006%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 5372549357
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2025823125 / 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 | $10,660.00 | $4,797.00 | — | — | DeniedCO29 |
| Totals | $10,660.00 | $4,797.00 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-799698
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001014; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-09-15: NULL (PPO), effective 2021-02-01. | |
| Timely filing | Fail | CO29 | Received 217 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025823125 on file for 29881. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Bone and Joint Center2025-09-15 15:30
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-04-20 05:05
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-20 08:19
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025823125_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-09-15 to 2025-12-14.
- Itemized billitemized_PA-799698.pdf9 pages
Itemised statement totalling $10660.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-001014; payment withheld until the identity is confirmed. Timely filing: Received 217 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.