CLM-2026-024868
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-30 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Judith Ford
- Member ID
- UHC-34094-33
- Date of birth
- 1949-12-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420520
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-0953
- Coverage period
- 2022-06-01 to 2026-03-27
- Deductible
- $53.21 of $500.0011%
- Out-of-pocket maximum
- $618.78 of $2,000.0031%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 8540511200
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $259.00 | $160.58 | — | — | DeniedCO27 |
| Totals | $259.00 | $160.58 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-710835
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000431 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-30 is after coverage terminated on 2026-03-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Orthopedic Specialists (2414063810). | |
| 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 Orthopedic Specialists2026-06-30 14:58
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-07 02:26
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-07 14:43
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-30 is after coverage terminated on 2026-03-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015469 | 2026-08-05 | Pinecrest Bone and Joint Center | $152.00 | Denied |
| CLM-2026-025889 | 2025-12-26 | Harbor Bone and Joint Center | $2,422.00 | Needs review |
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.