CLM-2026-034480
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Jean Santiago
- Member ID
- UHC-49960-87
- Date of birth
- 1943-08-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403074
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6746
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,931.87 of $2,500.0077%
- Out-of-pocket maximum
- $3,150.52 of $10,000.0032%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 6342853846
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- PA2025228362 / REF235019
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 | $5,561.00 | $2,502.45 | — | — | DeniedCO204 |
| Totals | $5,561.00 | $2,502.45 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-856955
- 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-035496 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-09: CORE-HMO (HMO), effective 2023-07-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025228362 on file for 29881. | |
| Provider network | Fail | CO204 | Billing provider 9793653152 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Bone and Joint Center2026-07-09 16:15
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-22 06:10
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-22 13:08
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025228362_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-07-09 to 2026-10-07.
- Itemized billitemized_PA-856955.pdf9 pages
Itemised statement totalling $5561.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 9793653152 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.