Claims workbench/CLM-2026-032936

Institutional claim · UB-04 · EDI 837I

CLM-2026-032936

Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-07-16 to 2026-07-20 at inpatient hospital (POS 21). Received 2026-07-30.

DeniedOut of network

Billed

$35,201.00

1 line

Allowed

$15,840.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Vicky Cook
Member ID: UHC-08669-16
Date of birth: 1987-07-25
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-423397
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-1322
Coverage period: 2021-02-01 to 2026-04-21
Deductible: $2,247.66 of $2,500.0090%
Out-of-pocket maximum: $908.75 of $7,500.0012%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 7 of 20 used

Provider

Billing and rendering

Billing provider: Valley Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 9793653152
Network: Out of network
Rendering NPI: 4196961377
Location: Mesa, AZ · TIN 68-9887889
Authorisation / referral: PA2025283881 / 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	27447 rev 0360	Total knee arthroplasty	—	1	1	$35,201.00	$15,840.45	—	—	DeniedCO27
Totals						$35,201.00	$15,840.45	—	—

Diagnoses (ICD-10-CM)

1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal

Claim header

Patient account: PA-241085
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-07-16 to 2026-07-18
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-011740 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-07-16 is after coverage terminated on 2026-04-21. Expenses incurred after coverage terminated
Timely filing	Pass		Received 10 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025283881 on file for 27447.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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	Review	HIGH	Billed $35,201.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Bone and Joint Center2026-07-20 13:30
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-07-30 00:23
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-30 16:47
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025283881_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-07-16 to 2026-10-14.
Itemized billitemized_PA-241085.pdf3 pages
Itemised statement totalling $35201.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-07-16 is after coverage terminated on 2026-04-21. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $35,201.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-011815	2026-05-18	Canyon Heart Institute	$7,707.00	Denied
CLM-2026-006853	2026-04-17	Summit Community Hospital	$1,726.00	Approved

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity