Claims workbench/CLM-2026-004719

Institutional claim · UB-04 · EDI 837I

CLM-2026-004719

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-10-07 to 2026-10-08 at inpatient hospital (POS 21). Received 2026-10-15.

DeniedOut of network

Billed

$39,961.00

1 line

Allowed

$17,982.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Douglas Harris
Member ID: UHC-15357-52
Date of birth: 1941-12-09
Identity: Verified5 records, confidence 0.97
Claim record: CLMCLM-409254
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-9796
Coverage period: 2024-11-01 to present
Deductible: $325.38 of $1,000.0033%
Out-of-pocket maximum: $502.59 of $4,000.0013%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 7 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3024134405
Network: Out of network
Rendering NPI: 6513051766
Location: Scottsdale, AZ · TIN 60-0197648
Authorisation / referral: none / 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	$39,961.00	$17,982.45	—	—	DeniedCO197
Totals						$39,961.00	$17,982.45	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter

Claim header

Patient account: PA-608473
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-10-07 to 2026-10-10
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-036271 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-10-07: NULL (PPO), effective 2024-11-01.
Timely filing	Pass		Received 7 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	27447 require precertification; no authorisation number on the claim. Precertification or authorization absent
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 $39,961.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2026-10-08 09:59
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-10-15 06:34
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-608473.pdf4 pages
Itemised statement totalling $39961.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 27447 require precertification; no authorisation number on the claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $39,961.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014214	2026-06-12	Valley Medical Group	$300.00	Approved
CLM-2026-021724	2026-06-13	Unity Bone and Joint Center	$194.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity