CLM-2026-029218
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-04-09 at outpatient hospital (POS 22). Received 2026-04-15.
Member
Resolved through the identity graph
- Member
- Arthur Gray
- Member ID
- UHC-88638-18
- Date of birth
- 1996-05-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421095
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5762
- Coverage period
- 2021-01-01 to 2026-02-10
- Deductible
- $946.13 of $3,500.0027%
- Out-of-pocket maximum
- $4,224.34 of $10,500.0040%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 2872997186
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2026918226 / REF498187
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 | $1,309.00 | $719.95 | — | — | DeniedCO27 |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1,2 | $8,234.00 | $4,528.70 | — | — | DeniedCO27 |
| Totals | $9,543.00 | $5,248.65 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-634521
- 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-004150 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-09 is after coverage terminated on 2026-02-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026918226 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Harbor Bone and Joint Center (1970418400). | |
| 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: Harbor Bone and Joint Center2026-04-09 16:24
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-15 06:40
Attachments
Documents received with the claim
- Prior auth letterPA2026918226_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-04-09 to 2026-07-08.
- Itemized billitemized_PA-634521.pdf5 pages
Itemised statement totalling $9543.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-09 is after coverage terminated on 2026-02-10.
Other claims for this member
Same resolved identity
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.