CLM-2026-026506
Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-09-10 at office (POS 11). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Andrew Woods
- Member ID
- UHC-24692-84
- Date of birth
- 2001-06-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404992
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2873
- Coverage period
- 2021-06-01 to present
- Deductible
- $9.60 of $500.002%
- Out-of-pocket maximum
- $221.39 of $1,000.0022%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 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
- 8889965157
- Location
- Mesa, AZ · TIN 68-9887889
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $184.00 | $82.80 | — | — | DeniedCO29 |
| Totals | $184.00 | $82.80 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-287447
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017067 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-10: SELECT-EPO (EPO), effective 2021-06-01. | |
| Timely filing | Fail | CO29 | Received 174 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 9793653152 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Center2025-09-10 10:40
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-03-03 02:58
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-03 15:39
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 174 days after the last date of service (limit 90). Provider network: Billing provider 9793653152 is out of network and the EPO plan has no out-of-network benefit.
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
Received after the timely-filing limit.