CLM-2026-000856
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-27 at outpatient hospital (POS 22). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Willie Hansen
- Member ID
- UHC-41836-57
- Date of birth
- 1941-12-16
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-412430
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1334
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,300.01 of $3,500.0037%
- Out-of-pocket maximum
- $1,969.64 of $7,000.0028%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 1280518352
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2025329290 / REF111386
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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,963.00 | $1,079.65 | $1,079.65 | $0.00 | Paid |
| Totals | $1,963.00 | $1,079.65 | $1,079.65 | $0.00 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-956250
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029465 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-27: NAVIGATE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025329290 on file for 73721. | |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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 Center2026-08-27 13:48
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025329290_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-08-27 to 2026-11-25.
- Itemized billitemized_PA-956250.pdf9 pages
Itemised statement totalling $1963.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016812 | 2026-07-19 | Unity Primary Care Associates | $264.00 | 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.