CLM-2026-027503
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Helen Wright
- Member ID
- UHC-67550-86
- Date of birth
- 1968-04-24
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420352
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3070
- Coverage period
- 2022-11-01 to present
- Deductible
- $2.58 of $1,000.000%
- Out-of-pocket maximum
- $606.83 of $4,000.0015%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 9121430299
- Location
- Scottsdale, AZ · TIN 78-6151009
- Authorisation / referral
- none / REF940785
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 | $2,267.00 | $1,246.85 | — | — | DeniedCO197 |
| Totals | $2,267.00 | $1,246.85 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-169495
- 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-006327 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-13: CORE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (8824040173). | |
| 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 Center2026-02-13 11:19
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-10 00:48
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-10 16:25
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-169495.pdf8 pages
Itemised statement totalling $2267.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034506 | 2026-09-27 | Canyon Diagnostic Imaging | $410.00 | Approved |
| CLM-2026-030737 | 2026-03-06 | Unity Community Hospital | $3,018.00 | 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
Precertification required and absent.