CLM-2026-003556
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-23 to 2025-12-25 at inpatient hospital (POS 21). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Frank Washington
- Member ID
- UHC-91228-72
- Date of birth
- 1978-07-08
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-424656
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5992
- Coverage period
- 2024-07-01 to present
- Deductible
- $134.87 of $500.0027%
- Out-of-pocket maximum
- $202.46 of $1,500.0013%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5513308960
- Network
- In network
- Rendering NPI
- 8935951169
- Location
- Minneapolis, MN · TIN 38-7701279
- Authorisation / referral
- PA2025614439 / 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 | $43,128.00 | $23,720.40 | — | — | Review |
| Totals | $43,128.00 | $23,720.40 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-175918
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-23 to 2025-12-27
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005739 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-23: SELECT-EPO (EPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025614439 on file for 27447. | |
| Provider network | Pass | In-network provider Riverside Orthopedic Specialists (5513308960). | |
| 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 $43,128.00 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: Riverside Orthopedic Specialists2025-12-25 15:09
Patient seen for other tear of medial meniscus, right knee, initial encounter. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-19 05:24
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-19 16:46
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025614439_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-23 to 2026-03-23.
- Itemized billitemized_PA-175918.pdf4 pages
Itemised statement totalling $43128.00 across 1 line.
- Medical recordrecords_PA-175918.pdf16 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44High-dollar review: Billed $43,128.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-23 19:19The claim for total knee arthroplasty is supported by the member's active coverage [COV], in-network provider status [R-network], and prior authorisation [R-prior_auth]. The clinical note [N1] and discharge summary [A3] confirm the medical necessity and completion of the procedure. Although the billed amount [C] exceeds the auto-adjudication ceiling [R-high_dollar], the claim is otherwise complete and passes all other checks. The allowed amount is $23,720.40, which is within the member's coverage limits.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · cf2cbaed
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025845 | 2026-05-28 | Harbor Physical Therapy | $255.00 | Approved |
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 member's active coverage [COV], in-network provider status [R-network], and prior authorisation [R-prior_auth]. The clinical note [N1] and discharge summary [A3] confirm the medical necessity and completion of the procedure. Although the billed amount [C] exceeds the auto-adjudication ceiling [R-high_dollar], the claim is otherwise complete and passes all other checks. The allowed amount is $23,720.40, which is within the member's coverage limits.
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.