CLM-2026-023903
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-05-31 at outpatient hospital (POS 22). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Hannah Padilla
- Member ID
- UHC-70306-47
- Date of birth
- 1982-06-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401101
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2731
- Coverage period
- 2022-06-01 to 2026-01-17
- Deductible
- $1,854.08 of $3,500.0053%
- Out-of-pocket maximum
- $1,523.31 of $10,500.0015%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 6543297314
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2026477417 / 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 | $6,695.00 | $3,012.75 | — | — | DeniedCO27 |
| Totals | $6,695.00 | $3,012.75 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-784265
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004083 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-31 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026477417 on file for 29881. | |
| Provider network | Fail | CO204 | Billing provider 9793653152 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Bone and Joint Center2026-05-31 14:01
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-06-20 03:52
Attachments
Documents received with the claim
- Prior auth letterPA2026477417_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-31 to 2026-08-29.
- Itemized billitemized_PA-784265.pdf5 pages
Itemised statement totalling $6695.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-31 is after coverage terminated on 2026-01-17. Provider network: Billing provider 9793653152 is out of network and the EPO plan has no out-of-network benefit.
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
Service after coverage termination.