CLM-2026-027414
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-09-23 at outpatient hospital (POS 22). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Gregory Hunt
- Member ID
- UHC-84710-60
- Date of birth
- 1978-09-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405155
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5370
- Coverage period
- 2024-09-01 to 2026-08-28
- Deductible
- $232.74 of $1,500.0016%
- Out-of-pocket maximum
- $1,012.55 of $6,000.0017%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 3197515885
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2025934868 / 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 | $6,359.00 | $3,497.45 | — | — | DeniedCO27 |
| Totals | $6,359.00 | $3,497.45 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-438272
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-024037 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-23 is after coverage terminated on 2026-08-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025934868 on file for 29881. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-09-23 10:57
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-10-15 06:50
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-15 16:09
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025934868_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-09-23 to 2026-12-22.
- Itemized billitemized_PA-438272.pdf7 pages
Itemised statement totalling $6359.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-23 is after coverage terminated on 2026-08-28.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009088 | 2026-03-06 | Pinecrest Bone and Joint Center | $6,822.00 | Approved |
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.