CLM-2026-003758
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-16 at office (POS 11). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Carl Coleman
- Member ID
- UHC-95130-07
- Date of birth
- 1970-03-15
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-425484
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2535
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,295.62 of $1,500.0086%
- Out-of-pocket maximum
- $179.00 of $4,500.004%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 7621472936
- Location
- Miami, FL · TIN 98-4961021
- 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 | $307.00 | $190.34 | — | — | DeniedCO18 |
| Totals | $307.00 | $190.34 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-255775
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-013224 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-16: NAVIGATE-HMO (HMO), effective 2021-09-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003757: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Orthopedic Specialists (6545828207). | |
| 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: Northgate Orthopedic Specialists2026-06-16 09:32
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-31 05:55
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-31 12:47
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003757: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016318 | 2026-08-07 | Riverside Medical Group | $36.00 | Approved |
| CLM-2026-007982 | 2026-06-30 | Cornerstone Internal Medicine Associates | $397.00 | Approved |
| CLM-2026-003757 | 2026-06-16 | Northgate Orthopedic Specialists | $307.00 | Approved |
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
Exact duplicate of an earlier submission.