Claims workbench/CLM-2026-023265

Institutional claim · UB-04 · Provider portal

CLM-2026-023265

Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-06-23.

DeniedIdentity on hold: CASE-001430

Billed

$8,896.00

2 lines

Allowed

$4,892.80

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Maria Welch
Member ID: none on golden record
Date of birth: 1950-04-01
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-432134
Relationship: Child

Coverage and accumulators

Found by name and date of birth

Plan: MEDICARE-ADV-A MA group GRP-0238
Coverage period: 2023-05-01 to present
Deductible: $142.08 of $500.0028%
Out-of-pocket maximum: $593.16 of $1,500.0040%
Copays: office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3990196263
Network: In network
Rendering NPI: 2958302335
Location: Denver, CO · TIN 27-9633140
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	$1,880.00	$1,034.00	—	—	DeniedCO197
2	29881 rev 0360	Knee arthroscopy with meniscectomy	—	1	2	$7,016.00	$3,858.80	—	—	DeniedCO197
Totals						$8,896.00	$4,892.80	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. M17.11 Unilateral primary osteoarthritis, right knee
3. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-836472
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001430; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-06: MEDICARE-ADV-A (MA), effective 2023-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 17 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	73721, 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Pinecrest Bone and Joint Center (3990196263).
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: Pinecrest Bone and Joint Center2026-06-06 18:20
Follow-up for pain in right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-23 01:16
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-23 10:19
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-836472.pdf4 pages
Itemised statement totalling $8896.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-001430; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-06: MEDICARE-ADV-A (MA), effective 2023-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: 73721, 29881 require precertification; no authorisation number on the claim.

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity