CLM-2026-002281
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2025-12-25 to 2025-12-26 at inpatient hospital (POS 21). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Andrew Harper
- Member ID
- UHC-15603-56
- Date of birth
- 1978-03-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400957
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6776
- Coverage period
- 2022-08-01 to present
- Deductible
- $811.68 of $1,000.0081%
- Out-of-pocket maximum
- $970.66 of $2,000.0049%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 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
- 7452950315
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2026821322 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $47,343.00 | $21,304.35 | — | — | Review |
| Totals | $47,343.00 | $21,304.35 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-166190
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-25 to 2025-12-28
- 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-001967 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: OPTIONS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026821322 on file for 27447. | |
| 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 | Review | HIGH | Billed $47,343.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Bone and Joint Center2025-12-26 10:14
Patient seen for pain in right knee. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-07 06:18
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-07 10:46
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026821322_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-25 to 2026-03-25.
- Itemized billitemized_PA-166190.pdf3 pages
Itemised statement totalling $47343.00 across 1 line.
- Medical recordrecords_PA-166190.pdf15 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $47,343.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-21 14:15The claim for total knee arthroplasty is supported by the prior authorisation [A1], the clinical note [N1], and the medical record [A3]. The member is eligible and the service is medically necessary. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off [N2]. The provider is out-of-network, but the service is covered under the member's plan. The claim is not a duplicate and is within the timely filing limit. All required documentation is present.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 935c5fc8
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for total knee arthroplasty is supported by the prior authorisation [A1], the clinical note [N1], and the medical record [A3]. The member is eligible and the service is medically necessary. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off [N2]. The provider is out-of-network, but the service is covered under the member's plan. The claim is not a duplicate and is within the timely filing limit. All required documentation is present.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Above auto-pay ceiling; payable once an examiner signs off.