CLM-2026-001295
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-09-12 at office (POS 11). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Russell Morales
- Member ID
- UHC-05073-10
- Date of birth
- 1969-02-22
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-404944
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2270
- Coverage period
- 2025-10-01 to 2026-03-19
- Deductible
- $1,725.32 of $2,500.0069%
- Out-of-pocket maximum
- $2,529.22 of $7,500.0034%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 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
- 2057024319
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- none / none
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 | $244.00 | $109.80 | — | — | DeniedCO27 |
| Totals | $244.00 | $109.80 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-559208
- 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-028890 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-12 is after coverage terminated on 2026-03-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 | 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 Center2026-09-12 12:52
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-10-10 00:43
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-10 09:28
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 2026-09-12 is after coverage terminated on 2026-03-19. 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007394 | 2026-04-20 | Harbor Primary Care Associates | $280.00 | Denied |
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.