CLM-2026-005604
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-08 at outpatient hospital (POS 22). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Jeremy Garrett
- Member ID
- UHC-79001-22
- Date of birth
- 1946-10-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431231
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7096
- Coverage period
- 2025-12-01 to present
- Deductible
- $182.35 of $500.0036%
- Out-of-pocket maximum
- $138.28 of $1,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 1719443347
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- PA2026786290 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,241.00 | $5,632.55 | $1,912.12 | $3,720.43 | Paid |
| Totals | $10,241.00 | $5,632.55 | $1,912.12 | $3,720.43 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-833586
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018729 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-08: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026786290 on file for 29881. | |
| 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 Specialists2026-03-08 12:57
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026786290_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-08 to 2026-06-06.
- Itemized billitemized_PA-833586.pdf4 pages
Itemised statement totalling $10241.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033972 | 2026-08-23 | Lakeside Clinical Laboratories | $96.00 | Needs review |
| CLM-2026-005605 | 2026-03-08 | Northgate Orthopedic Specialists | $10,241.00 | Needs review |
| CLM-2026-010530 | 2026-03-03 | Harbor Family Practice | $532.00 | Approved |
| CLM-2026-016077 | 2026-02-11 | Mesa Internal Medicine Associates | $354.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.