Claims workbench/CLM-2026-022851

Institutional claim · UB-04 · EDI 837I

CLM-2026-022851

Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-02 at outpatient hospital (POS 22). Received 2026-10-18.

DeniedOut of network

Billed

$8,489.00

1 line

Allowed

$3,820.05

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Pamela Tran
Member ID: UHC-95837-67
Date of birth: 2004-09-25
Identity: Verified3 records, confidence 1.00
Claim record: CLMCLM-413414
Relationship: Self, Glendale, AZ

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-4601
Coverage period: 2025-03-01 to present
Deductible: $1,424.49 of $3,500.0041%
Out-of-pocket maximum: $5,601.47 of $14,000.0040%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Cornerstone Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7007014674
Network: Out of network
Rendering NPI: 7156644321
Location: San Diego, CA · TIN 68-2977448
Authorisation / referral: PA2025427430 / 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	29881 rev 0360	Knee arthroscopy with meniscectomy	—	1	1	$8,489.00	$3,820.05	—	—	DeniedCO29
Totals						$8,489.00	$3,820.05	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal

Claim header

Patient account: PA-975278
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-025846 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-04-02: OPTIONS-PPO (PPO), effective 2025-03-01.
Timely filing	Fail	CO29	Received 199 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025427430 on file for 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)	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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Cornerstone Orthopedic Specialists2026-04-02 14:44
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-10-18 03:26
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-18 11:14
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025427430_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-02 to 2026-07-01.
Itemized billitemized_PA-975278.pdf2 pages
Itemised statement totalling $8489.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 199 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

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

Denied by Claims rules engine; an examiner may still override

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity