CLM-2026-025905
Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-12-10 at outpatient hospital (POS 22). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Kimberly Harvey
- Member ID
- UHC-10955-58
- Date of birth
- 1986-05-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415662
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4495
- Coverage period
- 2023-04-01 to present
- Deductible
- $852.64 of $1,000.0085%
- Out-of-pocket maximum
- $462.95 of $2,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 5488653390
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2026142572 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $6,173.00 | $2,777.85 | $410.41 | $2,367.44 | Paid |
| Totals | $6,173.00 | $2,777.85 | $410.41 | $2,367.44 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-394122
- 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-004475 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-10: CHOICE-PLUS-PPO (PPO), effective 2023-04-01. | |
| 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 PA2026142572 on file for 29881. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Bone and Joint Center2025-12-10 17:21
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026142572_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-12-10 to 2026-03-10.
- Itemized billitemized_PA-394122.pdf7 pages
Itemised statement totalling $6173.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030064 | 2025-12-21 | Desert Rehabilitation Center | $347.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.