Claims workbench/CLM-2026-004961

Institutional claim · UB-04 · EDI 837I

CLM-2026-004961

Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-31 to 2026-02-02 at inpatient hospital (POS 21). Received 2026-02-20.

Denied

Billed

$43,934.00

1 line

Allowed

$24,163.70

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Melissa Hawkins
Member ID: UHC-87638-87
Date of birth: 1975-06-26
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-428094
Relationship: Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-1691
Coverage period: 2024-02-01 to present
Deductible: $54.11 of $1,500.004%
Out-of-pocket maximum: $1,545.00 of $6,000.0026%
Copays: office $25.00, specialist $50.00, emergency $150.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 4209374246
Network: In network
Rendering NPI: 3095694980
Location: Miami, FL · TIN 51-8195966
Authorisation / referral: PA2025820883 / REF252343

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	$43,934.00	$24,163.70	—	—	DeniedCO18
Totals						$43,934.00	$24,163.70	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-216832
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-01-31 to 2026-02-01
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-010095 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-31: NAVIGATE-HMO (HMO), effective 2024-02-01.
Timely filing	Pass		Received 18 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-004960: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025820883 on file for 27447.
Provider network	Pass		In-network provider Riverside Orthopedic Specialists (4209374246).
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 $43,934.00 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 Orthopedic Specialists2026-02-02 16:04
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-02-20 03:43
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-20 16:58
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025820883_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-01-31 to 2026-05-01.
Itemized billitemized_PA-216832.pdf9 pages
Itemised statement totalling $43934.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-004960: same member, date of service, procedures and billing provider. High-dollar review: Billed $43,934.00 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-2026-013471	2026-03-20	Canyon Counseling Center	$217.00	Denied
CLM-2026-006398	2026-02-10	Desert Medical Group	$76.00	Approved
CLM-2026-004960	2026-01-31	Riverside Orthopedic Specialists	$43,934.00	Needs review
CLM-2026-016172	2025-12-21	Northgate Imaging Center	$2,243.00	Denied

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity