CLM-2026-006850
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-17 at outpatient hospital (POS 22). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Alexander Carter
- Member ID
- UHC-35056-20
- Date of birth
- 1996-01-15
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-408498
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4293
- Coverage period
- 2022-10-01 to present
- Deductible
- $360.90 of $500.0072%
- Out-of-pocket maximum
- $245.65 of $1,500.0016%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3024134405
- Network
- Out of network
- Rendering NPI
- 4601155334
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- PA2025327149 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,293.00 | $1,031.85 | $228.38 | $803.47 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $6,379.00 | $2,870.55 | $287.06 | $2,583.49 | Paid |
| Totals | $8,672.00 | $3,902.40 | $515.44 | $3,386.96 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-606762
- 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-012069 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-17: MEDICARE-ADV-A (MA), effective 2022-10-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025327149 on file for 73721, 29881. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Riverside Bone and Joint Center2026-07-17 14:31
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025327149_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-07-17 to 2026-10-15.
- Itemized billitemized_PA-606762.pdf2 pages
Itemised statement totalling $8672.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023520 | 2026-01-04 | Sunrise Skin Care Associates | $167.00 | 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.