CLM-2026-021810
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2025-12-18 at outpatient hospital (POS 22). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Carolyn Fuller
- Member ID
- UHC-59404-46
- Date of birth
- 1949-04-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-402636
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0256
- Coverage period
- 2025-04-01 to present
- Deductible
- $996.86 of $1,500.0066%
- Out-of-pocket maximum
- $1,061.72 of $3,000.0035%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 2647259326
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2026925071 / 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 | $2,275.00 | $1,251.25 | $577.95 | $673.30 | Paid |
| Totals | $2,275.00 | $1,251.25 | $577.95 | $673.30 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-540624
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004581 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-18: SELECT-EPO (EPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026925071 on file for 73721. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2025-12-18 11:28
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026925071_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-12-18 to 2026-03-18.
- Itemized billitemized_PA-540624.pdf5 pages
Itemised statement totalling $2275.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.