CLM-2026-029258
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-04-28 at outpatient hospital (POS 22). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Jennifer Hernandez
- Member ID
- UHC-59220-89
- Date of birth
- 1993-04-16
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-408186
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8281
- Coverage period
- 2023-07-01 to present
- Deductible
- $162.57 of $1,500.0011%
- Out-of-pocket maximum
- $1,832.23 of $4,500.0041%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8824040173
- Network
- In network
- Rendering NPI
- 5849872986
- Location
- Scottsdale, AZ · TIN 78-6151009
- Authorisation / referral
- PA2025160216 / 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 | $6,796.00 | $3,737.80 | $2,057.54 | $1,680.26 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1,2 | $1,818.00 | $999.90 | $299.97 | $699.93 | Paid |
| Totals | $8,614.00 | $4,737.70 | $2,357.51 | $2,380.19 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-594834
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031566 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-28: MEDICARE-ADV-B (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025160216 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (8824040173). | |
| 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 Center2026-04-28 18:45
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025160216_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-28 to 2026-07-27.
- Itemized billitemized_PA-594834.pdf7 pages
Itemised statement totalling $8614.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.