CLM-2026-005426
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-04 at office (POS 11). Received 2026-07-24.
Member
Resolved through the identity graph
- Member
- Noah Torres
- Member ID
- UHC-06965-04
- Date of birth
- 1979-09-16
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-421484
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7319
- Coverage period
- 2021-05-01 to present
- Deductible
- $265.74 of $500.0053%
- Out-of-pocket maximum
- $489.77 of $1,000.0049%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 5814899956
- Location
- San Diego, CA · TIN 43-7655262
- 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 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $232.00 | $143.84 | — | — | Review |
| 2 | 20610 | Joint injection, major joint | 59 | 1 | 1 | $230.00 | $142.60 | — | — | Review |
| Totals | $462.00 | $286.44 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-412459
- 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-035408 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-04: MEDICARE-ADV-B (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 20 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 Riverside Bone and Joint Center (5897697269). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Riverside Bone and Joint Center2026-07-04 16:24
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-07-24 04:46
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-24 14:55
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-412459.pdf10 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008168 | 2026-07-11 | Desert Family Practice | $464.00 | Approved |
| CLM-2026-030147 | 2026-06-13 | Canyon Cardiovascular Associates | $3,231.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Bundled code pair; modifier 59 not supported by the operative note.