CLM-2026-030839
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2025-12-31 at office (POS 11). Received 2026-02-10.
Member
Resolved through the identity graph
- Member
- Vincent Mitchell
- Member ID
- UHC-38991-46
- Date of birth
- 2004-07-10
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-412787
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6068
- Coverage period
- 2024-10-01 to present
- Deductible
- $44.10 of $500.009%
- Out-of-pocket maximum
- $324.83 of $1,500.0022%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 1675225852
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $225.00 | $139.50 | — | — | Review |
| Totals | $225.00 | $139.50 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M25.561 Pain in right knee
- Patient account
- PA-344228
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-011875 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-31: MEDICARE-ADV-A (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 | Review | CO16 | Documentation incomplete: “Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dic”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Bone and Joint Center2025-12-31 11:02
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-10 05:46
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-10 14:53
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dic”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024912 | 2026-01-21 | Unity Digestive Health Center | $3,608.00 | Approved |
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
Development letter outstanding.