CLM-2026-026806
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-02-11 at outpatient hospital (POS 22). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Pamela Collins
- Member ID
- UHC-20336-22
- Date of birth
- 1942-09-03
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-412941
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0445
- Coverage period
- 2023-07-01 to present
- Deductible
- $163.82 of $1,000.0016%
- Out-of-pocket maximum
- $219.70 of $2,000.0011%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 12 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
- 7212060918
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2026361893 / 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 | $9,348.00 | $4,206.60 | $1,510.26 | $2,696.34 | Paid |
| Totals | $9,348.00 | $4,206.60 | $1,510.26 | $2,696.34 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-470092
- 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-001653 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-11: OPTIONS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026361893 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 Center2026-02-11 16:27
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026361893_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-11 to 2026-05-12.
- Itemized billitemized_PA-470092.pdf3 pages
Itemised statement totalling $9348.00 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
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.