CLM-2026-033726
Unity Bone and Joint Center, Orthopedic Surgery. Service 2025-12-13 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Joshua Vasquez
- Member ID
- UHC-79855-18
- Date of birth
- 1940-01-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-400745
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1806
- Coverage period
- 2023-04-01 to present
- Deductible
- $729.51 of $2,500.0029%
- Out-of-pocket maximum
- $2,916.74 of $10,000.0029%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 6583501815
- Location
- Los Angeles, CA · TIN 56-0316152
- 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 | $283.00 | $175.46 | — | — | DeniedCO18 |
| Totals | $283.00 | $175.46 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-884040
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001570 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: NULL (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-033725: 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 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 Center2025-12-13 17:45
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-08 01:52
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-08 16:53
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-033725: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033725 | 2025-12-13 | Unity Bone and Joint Center | $283.00 | 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.