Claims workbench/CLM-2026-005746

Institutional claim · UB-04 · EDI 837I

CLM-2026-005746

Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-10-01 at outpatient hospital (POS 22). Received 2026-10-03.

Needs review

Billed

$8,777.00

1 line

Allowed

$4,827.35

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Heather Fuller
Member ID: UHC-97671-82
Date of birth: 1938-09-04
Identity: Verified6 records, confidence 1.00
Claim record: CLMCLM-423862
Relationship: Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-1643
Coverage period: 2025-05-01 to present
Deductible: $2,129.16 of $3,500.0061%
Out-of-pocket maximum: $292.42 of $7,000.004%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 4209374246
Network: In network
Rendering NPI: 4259081493
Location: Miami, FL · TIN 51-8195966
Authorisation / referral: PA2025318434 / 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	$8,777.00	$4,827.35	—	—	Review
Totals						$8,777.00	$4,827.35	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-727411
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-002082 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-10-01: MEDICARE-ADV-B (MA), effective 2025-05-01.
Timely filing	Pass		Received 2 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025318434 on file for 29881.
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	Review	CO16	Documentation incomplete: “Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications re”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Orthopedic Specialists2026-10-01 18:20
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-10-03 06:02
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-03 11:23
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2025318434_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-10-01 to 2026-12-30.
Itemized billitemized_PA-727411.pdf7 pages
Itemised statement totalling $8777.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications re”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005135	2026-05-28	Pinecrest Bone and Joint Center	$7,115.00	Denied
CLM-2026-005134	2026-05-28	Pinecrest Bone and Joint Center	$7,115.00	Approved
CLM-2026-003654	2026-04-07	Pinecrest Primary Care Associates	$510.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity