Claims workbench/CLM-2026-021831
Institutional claim · UB-04 · EDI 837I

CLM-2026-021831

Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-05-30 at outpatient hospital (POS 22). Received 2026-06-25.

PendedIdentity on hold: CASE-003358
Billed
$10,353.00
1 line
Allowed
$5,694.15
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Tyler Ortiz
Member ID
none on golden record
Date of birth
1975-09-09
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-431347
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Unity Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI
5039337832
Network
In network
Rendering NPI
2785861362
Location
Los Angeles, CA · TIN 56-0316152
Authorisation / referral
PA2026503939 / REF648423

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
129881
rev 0360
Knee arthroscopy with meniscectomy—11$10,353.00$5,694.15——PendedIDQ
Totals$10,353.00$5,694.15——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
Patient account
PA-711752
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-003358; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 26 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026503939 on file for 29881.
Provider networkPassIn-network provider Unity Bone and Joint Center (5039337832).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Unity Bone and Joint Center2026-05-30 12:02

    Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Prior auth letterPA2026503939_approval.pdf2 pages

    Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-30 to 2026-08-28.

  • Itemized billitemized_PA-711752.pdf7 pages

    Itemised statement totalling $10353.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-003358; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

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

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity