CLM-2026-031592
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-04-08 at outpatient hospital (POS 22). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Russell Parker
- Member ID
- UHC-91285-73
- Date of birth
- 1970-08-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418989
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8491
- Coverage period
- 2021-08-01 to present
- Deductible
- $563.17 of $2,500.0023%
- Out-of-pocket maximum
- $3,853.31 of $10,000.0039%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 4967837905
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2026758767 / 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 | $6,712.00 | $3,691.60 | $2,287.78 | $1,403.82 | Paid |
| Totals | $6,712.00 | $3,691.60 | $2,287.78 | $1,403.82 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-981379
- 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-027855 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-08: OPTIONS-PPO (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026758767 on file for 29881. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (3990196263). | |
| 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 Center2026-04-08 16:51
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026758767_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-08 to 2026-07-07.
- Itemized billitemized_PA-981379.pdf4 pages
Itemised statement totalling $6712.00 across 1 line.
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.