CLM-2026-023818
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2025-12-30 to 2026-01-03 at inpatient hospital (POS 21). Received 2026-06-16.
Member
Resolved through the identity graph
- Member
- Charlotte Vasquez
- Member ID
- UHC-44379-73
- Date of birth
- 1941-01-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-430142
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5445
- Coverage period
- 2025-06-01 to present
- Deductible
- $281.51 of $1,500.0019%
- Out-of-pocket maximum
- $845.89 of $6,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 9950812708
- Location
- Scottsdale, AZ · TIN 78-6151009
- Authorisation / referral
- PA2026457261 / REF451199
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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $42,639.00 | $23,451.45 | — | — | DeniedCO29 |
| Totals | $42,639.00 | $23,451.45 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-590671
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-30 to 2026-01-03
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011826 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 164 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 PA2026457261 on file for 27447. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (8824040173). | |
| 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 | Review | HIGH | Billed $42,639.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-01-03 11:20
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-16 00:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026457261_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-30 to 2026-03-30.
- Itemized billitemized_PA-590671.pdf8 pages
Itemised statement totalling $42639.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 164 days after the last date of service (limit 90). High-dollar review: Billed $42,639.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.