CLM-2026-004420
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-26 at office (POS 11). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Madison Brooks
- Member ID
- UHC-66865-28
- Date of birth
- 1973-11-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423297
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group UNKNOWN
- Coverage period
- 2021-05-01 to 2026-03-16
- Deductible
- $366.64 of $500.0073%
- Out-of-pocket maximum
- $472.15 of $2,000.0024%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7225530493
- Network
- In network
- Rendering NPI
- 7181125189
- Location
- Charlotte, NC · TIN 40-3118368
- 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 | $191.00 | $118.42 | — | — | DeniedCO27 |
| Totals | $191.00 | $118.42 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-464965
- 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-037367 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-26 is after coverage terminated on 2026-03-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 18 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 | Pass | In-network provider Northgate Orthopedic Specialists (7225530493). | |
| 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 Specialists2026-07-26 10:27
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-13 02:32
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-13 11:35
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-26 is after coverage terminated on 2026-03-16.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024286 | 2026-06-19 | Heritage Community Hospital | $219.00 | 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.