CLM-2026-000259
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-05-30 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Madison Knight
- Member ID
- UHC-85507-79
- Date of birth
- 1984-02-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419288
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6935
- Coverage period
- 2023-11-01 to present
- Deductible
- $825.37 of $1,500.0055%
- Out-of-pocket maximum
- $614.70 of $6,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 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
- 6225382574
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- none / 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 | $7,673.00 | $3,452.85 | — | — | DeniedCO197 |
| Totals | $7,673.00 | $3,452.85 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-175181
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024435 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-30: NULL (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-05-30 15:01
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-09 02:45
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-09 16:37
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-175181.pdf5 pages
Itemised statement totalling $7673.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 require precertification; no authorisation number on the claim. Provider 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
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.