CLM-2026-006962
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-24 to 2026-01-26 at inpatient hospital (POS 21). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Amanda Jensen
- Member ID
- UHC-53230-53
- Date of birth
- 1965-12-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-400419
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1940
- Coverage period
- 2021-02-01 to present
- Deductible
- $279.93 of $1,000.0028%
- Out-of-pocket maximum
- $1,598.27 of $4,000.0040%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 8867312851
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2025702859 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $37,312.00 | $20,521.60 | — | — | Review |
| Totals | $37,312.00 | $20,521.60 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-423175
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-01-24 to 2026-01-25
- 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-018280 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-24: CORE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025702859 on file for 27447. | |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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 | Review | HIGH | Billed $37,312.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Bone and Joint Center2026-01-26 09:33
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-03-08 01:55
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2025702859_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-01-24 to 2026-04-24.
- Itemized billitemized_PA-423175.pdf3 pages
Itemised statement totalling $37312.00 across 1 line.
- Medical recordrecords_PA-423175.pdf21 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44High-dollar review: Billed $37,312.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
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
Above auto-pay ceiling; payable once an examiner signs off.