CLM-2026-022915
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-06-14 at office (POS 11). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Nicholas Oliver
- Member ID
- UHC-43570-25
- Date of birth
- 1967-01-18
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-430478
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3470
- Coverage period
- 2022-01-01 to present
- Deductible
- $257.61 of $500.0052%
- Out-of-pocket maximum
- $178.95 of $2,000.009%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 9547237542
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $231.00 | $143.22 | $60.00 | $83.22 | Paid |
| 2 | 20610 | Joint injection, major joint | — | 1 | 1 | $215.00 | $133.30 | $0.00 | $133.30 | Paid |
| Totals | $446.00 | $276.52 | $60.00 | $216.52 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-251547
- 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-018859 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-14: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 44 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 Center2026-06-14 13:40
Patient seen for pain in right knee. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-28 05:41
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-251547.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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017520 | 2026-08-24 | Meadow Primary Care Associates | $427.00 | Approved |
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.