CLM-2026-022438
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-08-05 at office (POS 11). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Ann Sims
- Member ID
- UHC-52306-01
- Date of birth
- 1973-12-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-417960
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2025-01-01 to present
- Deductible
- $344.23 of $500.0069%
- Out-of-pocket maximum
- $285.51 of $1,000.0029%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 8863527627
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $267.00 | $165.54 | $40.00 | $125.54 | Paid |
| Totals | $267.00 | $165.54 | $40.00 | $125.54 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-336230
- 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-023957 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-08-05 09:29
Patient seen for low back pain, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-05 01:27
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-336230.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
Authorisation must be confirmed with UM before payment.