CLM-2026-006983
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-09-20 at outpatient hospital (POS 22). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Carl Hill
- Member ID
- UHC-13848-92
- Date of birth
- 1994-10-06
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-403672
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8464
- Coverage period
- 2021-08-01 to present
- Deductible
- $890.41 of $3,500.0025%
- Out-of-pocket maximum
- $3,754.83 of $10,500.0036%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1493585297
- Network
- Out of network
- Rendering NPI
- 6587530877
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2025417113 / 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 | $9,739.00 | $4,382.55 | $2,964.18 | $1,418.37 | Paid |
| Totals | $9,739.00 | $4,382.55 | $2,964.18 | $1,418.37 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-191642
- 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-030952 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-20: MEDICARE-ADV-A (MA), effective 2021-08-01. | |
| 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 PA2025417113 on file for 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: Northgate Bone and Joint Center2026-09-20 17:31
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025417113_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-09-20 to 2026-12-19.
- Itemized billitemized_PA-191642.pdf5 pages
Itemised statement totalling $9739.00 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 13:43Provider 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-2026-018549 | 2026-05-28 | Harbor Family Practice | $17.00 | Needs review |
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.