CLM-2026-034039
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-10-01 at outpatient hospital (POS 22). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Tyler Meyer
- Member ID
- UHC-68314-07
- Date of birth
- 1949-04-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420549
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7215
- Coverage period
- 2025-08-01 to present
- Deductible
- $331.60 of $1,500.0022%
- Out-of-pocket maximum
- $904.49 of $3,000.0030%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1938450750
- Network
- In network
- Rendering NPI
- 5105123777
- Location
- Mesa, AZ · TIN 27-3094451
- Authorisation / referral
- PA2025357689 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,117.00 | $1,714.35 | — | — | Review |
| Totals | $3,117.00 | $1,714.35 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-715638
- 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-007743 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-01: OPTIONS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025357689 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Bone and Joint Center (1938450750). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-10-01 17:50
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-10-07 05:39
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-07 17:26
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025357689_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-10-01 to 2026-12-30.
- Itemized billitemized_PA-715638.pdf8 pages
Itemised statement totalling $3117.00 across 1 line.
- Medical recordrecords_PA-715638.pdf17 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016609 | 2025-12-30 | Evergreen Digestive Health Center | $4,111.00 | Approved |
| CLM-2026-023097 | 2025-12-21 | Heritage Community Hospital | $159.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Notes document medical necessity.