Claims workbench/CLM-2026-028168

Institutional claim · UB-04 · EDI 837I

CLM-2026-028168

Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2025-10-04 at outpatient hospital (POS 22). Received 2026-03-30.

DeniedOut of network

Billed

$11,530.00

2 lines

Allowed

$5,188.50

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29, CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Rebecca Gonzalez
Member ID: UHC-31410-51
Date of birth: 1944-09-04
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-421664
Relationship: Self, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-3887
Coverage period: 2025-03-01 to present
Deductible: $2,606.40 of $3,500.0074%
Out-of-pocket maximum: $2,178.14 of $10,500.0021%
Copays: office $25.00, specialist $40.00, emergency $250.00
Physical therapy visits: 7 of 20 used

Provider

Billing and rendering

Billing provider: Cornerstone Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7007014674
Network: Out of network
Rendering NPI: 8555088474
Location: San Diego, CA · TIN 68-2977448
Authorisation / referral: PA2025079753 / 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	$9,229.00	$4,153.05	—	—	DeniedCO29
2	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1,2	$2,301.00	$1,035.45	—	—	DeniedCO29
Totals						$11,530.00	$5,188.50	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
2. M17.11 Unilateral primary osteoarthritis, right knee

Claim header

Patient account: PA-380268
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-022994 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-10-04: SELECT-EPO (EPO), effective 2025-03-01.
Timely filing	Fail	CO29	Received 177 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		Authorisation PA2025079753 on file for 29881, 73721.
Provider network	Fail	CO204	Billing provider 7007014674 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Cornerstone Orthopedic Specialists2025-10-04 09:06
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-03-30 06:03
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

Prior auth letterPA2025079753_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-10-04 to 2026-01-02.
Itemized billitemized_PA-380268.pdf5 pages
Itemised statement totalling $11530.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 177 days after the last date of service (limit 90). Provider network: Billing provider 7007014674 is out of network and the EPO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity