CLM-2026-033910
Sunrise Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-16 at outpatient hospital (POS 22). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Sophia Patel
- Member ID
- UHC-74674-41
- Date of birth
- 2007-09-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430585
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6010
- Coverage period
- 2023-09-01 to present
- Deductible
- $706.75 of $1,000.0071%
- Out-of-pocket maximum
- $266.43 of $2,000.0013%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2414063810
- Network
- In network
- Rendering NPI
- 6090806517
- Location
- Phoenix, AZ · TIN 14-5056475
- Authorisation / referral
- PA2025071984 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,929.00 | $1,060.95 | $523.56 | $537.39 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,065.00 | $5,535.75 | $1,660.73 | $3,875.02 | Paid |
| Totals | $11,994.00 | $6,596.70 | $2,184.29 | $4,412.41 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-152188
- 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-035039 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-16: MEDICARE-ADV-A (MA), effective 2023-09-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025071984 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Sunrise Orthopedic Specialists (2414063810). | |
| 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 Orthopedic Specialists2026-09-16 09:59
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025071984_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-16 to 2026-12-15.
- Itemized billitemized_PA-152188.pdf4 pages
Itemised statement totalling $11994.00 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.