CLM-2026-000129
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-06-19 at outpatient hospital (POS 22). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Victoria Bennett
- Member ID
- UHC-20682-65
- Date of birth
- 1956-05-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403700
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6348
- Coverage period
- 2024-10-01 to present
- Deductible
- $1,009.06 of $1,500.0067%
- Out-of-pocket maximum
- $375.76 of $4,500.008%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1493585297
- Network
- Out of network
- Rendering NPI
- 5657032509
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2026497471 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,607.00 | $3,873.15 | $1,505.60 | $2,367.55 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1,2 | $1,985.00 | $893.25 | $267.97 | $625.28 | Paid |
| Totals | $10,592.00 | $4,766.40 | $1,773.57 | $2,992.83 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-873159
- 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-011885 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-19: MEDICARE-ADV-B (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026497471 on file for 29881, 73721. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Northgate Bone and Joint Center2026-06-19 10:09
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026497471_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-06-19 to 2026-09-17.
- Itemized billitemized_PA-873159.pdf3 pages
Itemised statement totalling $10592.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.