CLM-2026-006108
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-12.
Member
Resolved through the identity graph
- Member
- Henry Little
- Member ID
- UHC-93359-73
- Date of birth
- 1944-12-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403751
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2610
- Coverage period
- 2023-02-01 to present
- Deductible
- $13.95 of $500.003%
- Out-of-pocket maximum
- $302.77 of $1,000.0030%
- Copays
- office $25.00, specialist $40.00, 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
- 7430494212
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- PA2026845594 / 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 | $6,734.00 | $3,703.70 | $1,129.58 | $2,574.12 | Paid |
| Totals | $6,734.00 | $3,703.70 | $1,129.58 | $2,574.12 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-835924
- 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-001424 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-13: CHOICE-PLUS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026845594 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 Specialists2026-02-13 15:50
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026845594_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-13 to 2026-05-14.
- Itemized billitemized_PA-835924.pdf5 pages
Itemised statement totalling $6734.00 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-2026-025871 | 2026-05-04 | Summit Digestive Health Center | $1,866.00 | Approved |
| CLM-2026-002663 | 2025-12-16 | Desert Primary Care Associates | $257.00 | Denied |
| CLM-2026-031331 | 2026-04-02 | Evergreen Counseling Center | $299.00 | Approved |
| CLM-2026-021131 | 2026-03-29 | Meadow Diagnostic Imaging | $4,017.00 | 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.