CLM-2026-000254
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-03 at outpatient hospital (POS 22). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Emma White
- Member ID
- UHC-64207-18
- Date of birth
- 1975-07-18
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-415107
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3934
- Coverage period
- 2023-06-01 to present
- Deductible
- $303.53 of $500.0061%
- Out-of-pocket maximum
- $22.45 of $1,000.002%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3024134405
- Network
- Out of network
- Rendering NPI
- 8218911161
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- PA2025811485 / 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 | $5,983.00 | $2,692.35 | $446.06 | $2,246.29 | Paid |
| Totals | $5,983.00 | $2,692.35 | $446.06 | $2,246.29 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-848252
- 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-034494 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-03: OPTIONS-PPO (PPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025811485 on file for 29881. | |
| 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: Riverside Bone and Joint Center2026-05-03 18:59
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2025811485_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-03 to 2026-08-01.
- Itemized billitemized_PA-848252.pdf8 pages
Itemised statement totalling $5983.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019266 | 2026-05-11 | Canyon Medical Group | $507.00 | Approved |
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.