CLM-2026-034501
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-05-08 at office (POS 11). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Marcus Myers
- Member ID
- UHC-24628-03
- Date of birth
- 1989-08-13
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-424325
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8793
- Coverage period
- 2021-12-01 to 2026-02-07
- Deductible
- $248.91 of $500.0050%
- Out-of-pocket maximum
- $132.85 of $1,500.009%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3990196263
- Network
- In network
- Rendering NPI
- 2166457251
- Location
- Denver, CO · TIN 27-9633140
- Authorisation / referral
- none / REF398423
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 | $212.00 | $131.44 | — | — | DeniedCO27 |
| Totals | $212.00 | $131.44 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-749353
- 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-007272 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-08 is after coverage terminated on 2026-02-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-05-08 12:44
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-05-16 01:40
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-16 11:54
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-08 is after coverage terminated on 2026-02-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002685 | 2026-04-24 | Harbor Medical Group | $52.00 | Denied |
| CLM-2026-024857 | 2026-01-06 | Mesa Family Practice | $208.00 | 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
Service after coverage termination.