CLM-2026-025166
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-22 at office (POS 11). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Gerald Pierce
- Member ID
- none on golden record
- Date of birth
- 1996-11-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407238
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NULL PPO group GRP-1527
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,260.71 of $1,500.0084%
- Out-of-pocket maximum
- $1,237.40 of $3,000.0041%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 5778834791
- Location
- Scottsdale, AZ · TIN 78-6151009
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $169.00 | $104.78 | — | — | PendedIDQ |
| Totals | $169.00 | $104.78 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-350072
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000723; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-22: NULL (PPO), effective 2025-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 39 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 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-05-22 12:25
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000723; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-22: NULL (PPO), effective 2025-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.