CLM-2026-021460
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-03-05 at outpatient hospital (POS 22). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Amanda McDonald
- Member ID
- UHC-80724-56
- Date of birth
- 1961-09-28
- Identity
- Verified7 records, confidence 1.00
- Claim record
- CLMCLM-426491
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4405
- Coverage period
- 2021-05-01 to present
- Deductible
- $838.26 of $3,500.0024%
- Out-of-pocket maximum
- $1,715.08 of $7,000.0025%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 9719694710
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- none / 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 | $10,825.00 | $5,953.75 | — | — | DeniedCO197 |
| Totals | $10,825.00 | $5,953.75 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-959815
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020672 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-05: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Sunrise Bone and Joint Center (8496214718). | |
| 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: Sunrise Bone and Joint Center2026-03-05 11:30
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-31 05:03
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-959815.pdf5 pages
Itemised statement totalling $10825.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020786 | 2026-04-07 | Mesa Clinical Laboratories | $110.00 | Approved |
| CLM-2026-008484 | 2026-04-06 | Canyon Primary Care Associates | $216.00 | Approved |
| CLM-2026-008528 | 2026-03-06 | Evergreen Orthopedic Specialists | $151.00 | Approved |
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
Precertification required and absent.