CLM-2026-023127
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-02-19 at outpatient hospital (POS 22). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Charlotte Hanson
- Member ID
- UHC-64461-42
- Date of birth
- 1963-05-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422873
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9340
- Coverage period
- 2022-04-01 to present
- Deductible
- $388.49 of $1,500.0026%
- Out-of-pocket maximum
- $2,233.40 of $4,500.0050%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 2432054841
- Location
- Nashville, TN · TIN 33-7590536
- 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 | $2,271.00 | $1,249.05 | — | — | DeniedCO197 |
| Totals | $2,271.00 | $1,249.05 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-510100
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017644 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-19: MEDICARE-ADV-A (MA), effective 2022-04-01. | |
| Timely filing | Pass | Received 23 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 Sunrise Bone and Joint Center (8496214718). | |
| 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: Sunrise Bone and Joint Center2026-02-19 14:51
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-14 05:03
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-14 12:41
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-510100.pdf8 pages
Itemised statement totalling $2271.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009339 | 2026-05-30 | Mesa Clinical Laboratories | $264.00 | Approved |
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.