CLM-2026-028832
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-03-18 to 2026-03-20 at inpatient hospital (POS 21). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Judy Henry
- Member ID
- UHC-61460-03
- Date of birth
- 1987-05-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432414
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7913
- Coverage period
- 2025-04-01 to present
- Deductible
- $574.71 of $1,000.0057%
- Out-of-pocket maximum
- $901.25 of $3,000.0030%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 9994690185
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2026227412 / REF669175
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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $37,075.00 | $20,391.25 | — | — | Review |
| Totals | $37,075.00 | $20,391.25 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-377036
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-03-18 to 2026-03-19
- 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-004026 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-18: NAVIGATE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026227412 on file for 27447. | |
| 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 | Review | HIGH | Billed $37,075.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Bone and Joint Center2026-03-20 09:41
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026227412_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-03-18 to 2026-06-16.
- Itemized billitemized_PA-377036.pdf4 pages
Itemised statement totalling $37075.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $37,075.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007798 | 2026-07-29 | Pinecrest Diagnostic Imaging | $2,435.00 | Approved |
| CLM-2026-028833 | 2026-03-18 | Northgate Orthopedic Specialists | $37,075.00 | Needs review |
| CLM-2026-012226 | 2025-12-26 | Harbor Rehabilitation Center | $257.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.