CLM-2026-025902
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-03-14 at outpatient hospital (POS 22). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Brittany Luna
- Member ID
- UHC-53411-19
- Date of birth
- 1972-01-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401942
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7835
- Coverage period
- 2022-01-01 to 2026-03-12
- Deductible
- $165.96 of $500.0033%
- Out-of-pocket maximum
- $31.76 of $2,000.002%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 1241916984
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2025597064 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,700.00 | $935.00 | — | — | DeniedCO27 |
| Totals | $1,700.00 | $935.00 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-350912
- 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-020235 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-14 is after coverage terminated on 2026-03-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025597064 on file for 73721. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-03-14 10:11
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-03-17 02:55
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-17 12:17
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025597064_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-14 to 2026-06-12.
- Itemized billitemized_PA-350912.pdf9 pages
Itemised statement totalling $1700.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-14 is after coverage terminated on 2026-03-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001841 | 2026-01-23 | Lakeside Bone and Joint Center | $169.00 | Denied |
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.