CLM-2026-029542
Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Fetima Ramos
- Member ID
- none on golden record
- Date of birth
- 2001-02-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401405
- Relationship
- Spouse
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 3457314854
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2026452804 / REF582832
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 | $7,568.00 | $3,405.60 | — | — | PendedIDQ |
| Totals | $7,568.00 | $3,405.60 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-227274
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000558; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026452804 on file for 29881. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Bone and Joint Center2025-12-30 12:31
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-01-06 00:10
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026452804_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-12-30 to 2026-03-30.
- Itemized billitemized_PA-227274.pdf9 pages
Itemised statement totalling $7568.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000558; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.