CLM-2026-025182
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-06-14 to 2026-06-18 at inpatient hospital (POS 21). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Melissa Gardner
- Member ID
- UHC-50355-56
- Date of birth
- 1985-09-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430850
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group -
- Coverage period
- 2025-01-01 to 2026-04-27
- Deductible
- $382.08 of $1,500.0025%
- Out-of-pocket maximum
- $2,883.13 of $6,000.0048%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 6066196794
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2025065391 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $45,411.00 | $24,976.05 | — | — | DeniedCO27 |
| Totals | $45,411.00 | $24,976.05 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-464491
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-06-14 to 2026-06-16
- 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-037899 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-14 is after coverage terminated on 2026-04-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025065391 on file for 27447. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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 $45,411.00 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 Center2026-06-18 17:41
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-09 05:15
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-09 17:59
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025065391_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-06-14 to 2026-09-12.
- Itemized billitemized_PA-464491.pdf6 pages
Itemised statement totalling $45411.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-14 is after coverage terminated on 2026-04-27. High-dollar review: Billed $45,411.00 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
Service after coverage termination.