CLM-2026-032725
Harbor Bone and Joint Center, Orthopedic Surgery. Service 2026-04-11 at outpatient hospital (POS 22). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Josh Hudson
- Member ID
- UHC-06238-41
- Date of birth
- 1955-09-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427668
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6649
- Coverage period
- 2021-04-01 to present
- Deductible
- $302.15 of $2,500.0012%
- Out-of-pocket maximum
- $960.89 of $7,500.0013%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1970418400
- Network
- In network
- Rendering NPI
- 5576538453
- Location
- Tampa, FL · TIN 23-8846705
- Authorisation / referral
- PA2026656001 / 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 | $10,766.00 | $5,921.30 | $2,570.19 | $3,351.11 | Paid |
| Totals | $10,766.00 | $5,921.30 | $2,570.19 | $3,351.11 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-156000
- 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-019744 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-11: MEDICARE-ADV-A (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026656001 on file for 29881. | |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Bone and Joint Center2026-04-11 13:55
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026656001_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-11 to 2026-07-10.
- Itemized billitemized_PA-156000.pdf9 pages
Itemised statement totalling $10766.00 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.