CLM-2026-033662
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-01-10 at outpatient hospital (POS 22). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Henry Walker
- Member ID
- UHC-68040-52
- Date of birth
- 1993-04-15
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404517
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0332
- Coverage period
- 2024-04-01 to present
- Deductible
- $998.90 of $1,500.0067%
- Out-of-pocket maximum
- $962.71 of $6,000.0016%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 5359857815
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- PA2026369862 / 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 | $7,400.00 | $4,070.00 | $857.99 | $3,212.01 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,921.00 | $1,056.55 | $105.66 | $950.89 | Paid |
| Totals | $9,321.00 | $5,126.55 | $963.65 | $4,162.90 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-754548
- 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-003966 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-10: NULL (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026369862 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (3990196263). | |
| 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: Pinecrest Bone and Joint Center2026-01-10 11:25
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026369862_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-10 to 2026-04-10.
- Itemized billitemized_PA-754548.pdf8 pages
Itemised statement totalling $9321.00 across 2 lines.
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.