CLM-2026-028483
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-28 at outpatient hospital (POS 22). Received 2026-07-11.
Member
Resolved through the identity graph
- Member
- Jacqueline Daniels
- Member ID
- UHC-36475-82
- Date of birth
- 1999-10-28
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-423722
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2690
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,688.84 of $2,500.0068%
- Out-of-pocket maximum
- $431.58 of $5,000.009%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 6851524671
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2025158826 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,340.00 | $737.00 | $737.00 | $0.00 | Paid |
| Totals | $1,340.00 | $737.00 | $737.00 | $0.00 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-307106
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010663 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-28: MEDICARE-ADV-B (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025158826 on file for 73721. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (3990196263). | |
| 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 Center2026-05-28 10:46
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025158826_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-28 to 2026-08-26.
- Itemized billitemized_PA-307106.pdf7 pages
Itemised statement totalling $1340.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011612 | 2026-08-11 | Meadow Regional Medical Center | $924.00 | Approved |
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.