CLM-2026-031696
Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-23 at outpatient hospital (POS 22). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Ralph Campbell
- Member ID
- UHC-69425-15
- Date of birth
- 1989-10-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412816
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1319
- Coverage period
- 2024-08-01 to present
- Deductible
- $367.05 of $500.0073%
- Out-of-pocket maximum
- $817.47 of $2,000.0041%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3819335712
- Network
- In network
- Rendering NPI
- 5982583358
- Location
- Tampa, FL · TIN 32-1762387
- Authorisation / referral
- PA2026326732 / 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 | $8,579.00 | $4,718.45 | $591.50 | $4,126.95 | Paid |
| Totals | $8,579.00 | $4,718.45 | $591.50 | $4,126.95 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-724240
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014273 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-23: NULL (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026326732 on file for 29881. | |
| Provider network | Pass | In-network provider Heritage Orthopedic Specialists (3819335712). | |
| 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: Heritage Orthopedic Specialists2026-01-23 09:59
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026326732_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-23 to 2026-04-23.
- Itemized billitemized_PA-724240.pdf9 pages
Itemised statement totalling $8579.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019407 | 2026-07-16 | Meadow Primary Care Associates | $54.00 | Approved |
| CLM-2026-000037 | 2026-05-31 | Lakeside Internal Medicine Associates | $622.00 | Denied |
| CLM-2026-000036 | 2026-05-31 | Lakeside Internal Medicine Associates | $622.00 | Approved |
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.