Claims workbench/CLM-2026-032097
Institutional claim · UB-04 · EDI 837I

CLM-2026-032097

Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-10-05 at outpatient hospital (POS 22). Received 2026-10-12.

Approved
Billed
$8,972.00
1 line
Allowed
$4,934.60
contract rate applied
Plan pays
$2,076.65
approved
Member owes
$2,857.95
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Alexander Kennedy
Member ID
UHC-46150-15
Date of birth
1962-10-17
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-428455
Relationship
Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-9959
Coverage period
2022-12-01 to present
Deductible
$1,532.05 of $3,500.0044%
Out-of-pocket maximum
$972.72 of $7,000.0014%
Copays
office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits
7 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI
3990196263
Network
In network
Rendering NPI
2620736993
Location
Denver, CO · TIN 27-9633140
Authorisation / referral
PA2026328127 / REF761273

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
129881
rev 0360
Knee arthroscopy with meniscectomy—11$8,972.00$4,934.60$2,857.95$2,076.65Paid
Totals$8,972.00$4,934.60$2,857.95$2,076.65
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
Claim header
Patient account
PA-424793
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

CheckResultCodeDetail
Member identityPassAttached to MBR-044916 (verified, link confidence 0.99).
EligibilityPassActive on 2026-10-05: CORE-HMO (HMO), effective 2022-12-01.
Timely filingPassReceived 7 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026328127 on file for 29881.
Provider networkPassIn-network provider Pinecrest Bone and Joint Center (3990196263).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Bone and Joint Center2026-10-05 10:22

    Patient seen for pain in right knee.

Attachments

Documents received with the claim

  • Prior auth letterPA2026328127_approval.pdf2 pages

    Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-10-05 to 2027-01-03.

  • Itemized billitemized_PA-424793.pdf3 pages

    Itemised statement totalling $8972.00 across 1 line.

Explanation of benefits

What the member will see

Amount billed
$8,972.00
Plan discount
$4,037.40
contracted rate
Plan paid
$2,076.65
You may owe
$2,857.95
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity