CLM-2026-025313
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-27 to 2026-05-31 at inpatient hospital (POS 21). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Albert Payne
- Member ID
- UHC-86332-25
- Date of birth
- 1943-07-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409596
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6538
- Coverage period
- 2024-10-01 to present
- Deductible
- $544.09 of $3,500.0016%
- Out-of-pocket maximum
- $1,804.24 of $7,000.0026%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 7560505274
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2025195744 / 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 | $30,618.00 | $16,839.90 | — | — | Review |
| Totals | $30,618.00 | $16,839.90 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-535745
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-05-27 to 2026-05-28
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005955 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: MEDICARE-ADV-B (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025195744 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 $30,618.00 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 Center2026-05-31 17:21
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2025195744_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-05-27 to 2026-08-25.
- Itemized billitemized_PA-535745.pdf6 pages
Itemised statement totalling $30618.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $30,618.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025314 | 2026-05-27 | Pinecrest Bone and Joint Center | $30,618.00 | Needs review |
| CLM-2026-033857 | 2025-12-13 | Heritage Community Hospital | $3,180.00 | Approved |
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.