CLM-2026-029949
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-08-23 at outpatient hospital (POS 22). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Debra Meyer
- Member ID
- UHC-68461-30
- Date of birth
- 1981-02-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419140
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1326
- Coverage period
- 2022-02-01 to present
- Deductible
- $380.26 of $1,000.0038%
- Out-of-pocket maximum
- $291.36 of $3,000.0010%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 6772997394
- Location
- Tampa, FL · TIN 14-7269323
- Authorisation / referral
- PA2025470252 / 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 | $7,191.00 | $3,955.05 | $1,286.80 | $2,668.25 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | 25 | 1 | 1 | $1,457.00 | $801.35 | $160.27 | $641.08 | Paid |
| Totals | $8,648.00 | $4,756.40 | $1,447.07 | $3,309.33 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-343012
- 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-039894 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-23: SELECT-EPO (EPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025470252 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (2148364427). | |
| 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 Center2026-08-23 09:41
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025470252_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-23 to 2026-11-21.
- Itemized billitemized_PA-343012.pdf5 pages
Itemised statement totalling $8648.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029950 | 2026-08-23 | Riverside Orthopedic Specialists | $8,648.00 | Needs review |
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.