CLM-2026-032357
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-09-23 at outpatient hospital (POS 22). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Sara Baker
- Member ID
- UHC-05605-66
- Date of birth
- 1998-08-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432799
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1014
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,297.08 of $2,500.0052%
- Out-of-pocket maximum
- $585.76 of $5,000.0012%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 8625514442
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2025571549 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,193.00 | $656.15 | $656.15 | $0.00 | Paid |
| Totals | $1,193.00 | $656.15 | $656.15 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-903104
- 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-025162 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-23: MEDICARE-ADV-B (MA), effective 2024-02-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025571549 on file for 73721. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| 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: Unity Bone and Joint Center2026-09-23 13:06
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025571549_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-23 to 2026-12-22.
- Itemized billitemized_PA-903104.pdf6 pages
Itemised statement totalling $1193.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018284 | 2026-07-14 | Desert Medical Group | $75.00 | 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.