Claims workbench/CLM-2026-022265

Institutional claim · UB-04 · EDI 837I

CLM-2026-022265

Unity Bone and Joint Center, Orthopedic Surgery. Service 2025-12-17 to 2025-12-21 at inpatient hospital (POS 21). Received 2026-01-09.

PendedIdentity on hold: CASE-000384

Billed

$34,353.00

1 line

Allowed

$18,894.15

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Eugene Kelly
Member ID: none on golden record
Date of birth: 1976-07-07
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-407690
Relationship: Child

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-1415
Coverage period: 2024-05-01 to present
Deductible: $260.77 of $1,000.0026%
Out-of-pocket maximum: $537.75 of $3,000.0018%
Copays: office $25.00, specialist $50.00, emergency $150.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Unity Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 5039337832
Network: In network
Rendering NPI: 4945651253
Location: Los Angeles, CA · TIN 56-0316152
Authorisation / referral: PHONE-912746 / REF548195

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	27447 rev 0360	Total knee arthroplasty	—	1	1	$34,353.00	$18,894.15	—	—	PendedIDQ
Totals						$34,353.00	$18,894.15	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal

Claim header

Patient account: PA-253319
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2025-12-17 to 2025-12-18
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 4 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-000384; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2025-12-17: NAVIGATE-HMO (HMO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 19 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Review	CO197	Authorisation reference “PHONE-912746” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent
Provider network	Pass		In-network provider Unity Bone and Joint Center (5039337832).
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	Review	HIGH	Billed $34,353.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay 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 Center2025-12-21 12:30
Patient seen for unilateral primary osteoarthritis, left knee. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-01-09 02:56
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-09 14:59
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-253319.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Itemized billitemized_PA-253319.pdf7 pages
Itemised statement totalling $34353.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-000384; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-17: NAVIGATE-HMO (HMO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: Authorisation reference “PHONE-912746” does not match the utilisation-management format; must be confirmed before payment. High-dollar review: Billed $34,353.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

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

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity