CLM-2026-003160
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-21 at outpatient hospital (POS 22). Received 2026-06-03.
Member
Resolved through the identity graph
- Member
- Ralph Robinson
- Member ID
- UHC-20956-92
- Date of birth
- 1952-12-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432196
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0599
- Coverage period
- 2021-08-01 to present
- Deductible
- $244.56 of $500.0049%
- Out-of-pocket maximum
- $161.14 of $1,000.0016%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 8653854876
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- none / REF882274
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 | $1,672.00 | $919.60 | — | — | DeniedCO197 |
| Totals | $1,672.00 | $919.60 | — | — | ||||||
- 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-853843
- 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-033042 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-21: CORE-HMO (HMO), effective 2021-08-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-05-21 09:14
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-03 06:11
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-853843.pdf2 pages
Itemised statement totalling $1672.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 73721 require precertification; no authorisation number on the claim.
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.