CLM-2026-033003
Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-02-17 at office (POS 11). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Sharon Watson
- Member ID
- UHC-84466-70
- Date of birth
- 1967-08-23
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-425428
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9223
- Coverage period
- 2022-05-01 to present
- Deductible
- $526.28 of $1,000.0053%
- Out-of-pocket maximum
- $692.55 of $2,000.0035%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 8496214718
- Network
- In network
- Rendering NPI
- 6691849551
- Location
- Nashville, TN · TIN 33-7590536
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $295.00 | $182.90 | — | — | DeniedCO18 |
| Totals | $295.00 | $182.90 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-947892
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018637 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-17: MEDICARE-ADV-B (MA), effective 2022-05-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-033002: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Bone and Joint Center (8496214718). | |
| 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: Sunrise Bone and Joint Center2026-02-17 09:38
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-31 05:01
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-033002: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033002 | 2026-02-17 | Sunrise Bone and Joint Center | $295.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.