CLM-2026-024863
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-09-04 at outpatient hospital (POS 22). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Diana Hicks
- Member ID
- UHC-40573-29
- Date of birth
- 1962-09-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-410720
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9370
- Coverage period
- 2023-04-01 to present
- Deductible
- $940.49 of $1,500.0063%
- Out-of-pocket maximum
- $2,336.45 of $6,000.0039%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 6686336838
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- PA2025142171 / 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 | $5,550.00 | $3,052.50 | $808.81 | $2,243.69 | Paid |
| Totals | $5,550.00 | $3,052.50 | $808.81 | $2,243.69 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-829933
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-045069 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-04: MEDICARE-ADV-B (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025142171 on file for 29881. | |
| 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 Center2026-09-04 16:25
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025142171_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-09-04 to 2026-12-03.
- Itemized billitemized_PA-829933.pdf8 pages
Itemised statement totalling $5550.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.