CLM-2026-022436
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-06-08 at outpatient hospital (POS 22). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Ptaricia Dominguez
- Member ID
- UHC-15071-60
- Date of birth
- 1990-10-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425204
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-9136
- Coverage period
- 2025-06-01 to present
- Deductible
- $44.43 of $500.009%
- Out-of-pocket maximum
- $356.37 of $2,000.0018%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 5820564222
- Location
- Tampa, FL · TIN 23-8846705
- 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,872.00 | $1,029.60 | — | — | DeniedCO197 |
| Totals | $1,872.00 | $1,029.60 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-324216
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037213 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-08: N/A (PPO), effective 2025-06-01. | |
| 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 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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: Harbor Bone and Joint Center2026-06-08 09:56
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-07-04 04:37
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-324216.pdf7 pages
Itemised statement totalling $1872.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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.