CLM-2026-023533
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-03 at outpatient hospital (POS 22). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Olivia Carroll
- Member ID
- UHC-10954-37
- Date of birth
- 1965-03-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404296
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6193
- Coverage period
- 2024-01-01 to present
- Deductible
- $167.18 of $500.0033%
- Out-of-pocket maximum
- $791.62 of $2,000.0040%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 6318302620
- Location
- Tempe, AZ · TIN 82-7144175
- Authorisation / referral
- PA2026884166 / 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 | $8,301.00 | $4,565.55 | $1,179.37 | $3,386.18 | Paid |
| Totals | $8,301.00 | $4,565.55 | $1,179.37 | $3,386.18 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-403638
- 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-030735 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-03: MEDICARE-ADV-A (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026884166 on file for 29881. | |
| Provider network | Pass | In-network provider Evergreen Orthopedic Specialists (4479500462). | |
| 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: Evergreen Orthopedic Specialists2026-05-03 11:15
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026884166_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-03 to 2026-08-01.
- Itemized billitemized_PA-403638.pdf9 pages
Itemised statement totalling $8301.00 across 1 line.
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-2026-014582 | 2026-08-09 | Northgate Orthopedic Specialists | $166.00 | Approved |
| CLM-2026-023534 | 2026-05-03 | Evergreen Orthopedic Specialists | $8,301.00 | Denied |
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
Clean claim, priced at contract rate.