CLM-2026-022349
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-02-04 to 2026-02-08 at inpatient hospital (POS 21). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Lauren Wagner
- Member ID
- UHC-76656-69
- Date of birth
- 1959-01-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-429126
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4902
- Coverage period
- 2025-04-01 to present
- Deductible
- $413.86 of $500.0083%
- Out-of-pocket maximum
- $464.16 of $1,000.0046%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 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
- 3135708220
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2025407188 / 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 | 27447 rev 0360 | Total knee arthroplasty | 59 | 1 | 1 | $45,126.00 | $20,306.70 | — | — | Review |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | 59 | 1 | 1 | $5,822.00 | $2,619.90 | — | — | Review |
| Totals | $50,948.00 | $22,926.60 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-144533
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-02-04 to 2026-02-08
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015498 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-04: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025407188 on file for 27447, 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Review | HIGH | Billed $50,948.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Bone and Joint Center2026-02-08 15:00
Patient seen for unilateral primary osteoarthritis, left knee. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-03-21 02:42
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Prior auth letterPA2025407188_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-02-04 to 2026-05-05.
- Itemized billitemized_PA-144533.pdf5 pages
Itemised statement totalling $50948.00 across 2 lines.
- Medical recordrecords_PA-144533.pdf5 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. High-dollar review: Billed $50,948.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023765 | 2026-05-28 | Pinecrest Physical Therapy | $483.00 | Approved |
| CLM-2026-023573 | 2026-03-29 | Pinecrest Reference Lab | $179.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.