CLM-2026-027886
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-05-13 at outpatient hospital (POS 22). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Carol Ellis
- Member ID
- UHC-90522-90
- Date of birth
- 1954-09-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411419
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8802
- Coverage period
- 2025-11-01 to 2026-02-28
- Deductible
- $186.97 of $1,500.0012%
- Out-of-pocket maximum
- $1,152.31 of $6,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 2873209235
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2026104334 / 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 | $8,916.00 | $4,903.80 | — | — | DeniedCO27 |
| Totals | $8,916.00 | $4,903.80 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-430621
- 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-005094 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-13 is after coverage terminated on 2026-02-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026104334 on file for 29881. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-05-13 16:32
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-16 00:24
Attachments
Documents received with the claim
- Prior auth letterPA2026104334_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-13 to 2026-08-11.
- Itemized billitemized_PA-430621.pdf8 pages
Itemised statement totalling $8916.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-13 is after coverage terminated on 2026-02-28.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013831 | 2025-12-04 | Unity Digestive Health Center | $1,953.00 | 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.