Claims workbench/CLM-2026-007941

Institutional claim · UB-04 · EDI 837I

CLM-2026-007941

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-17 at outpatient hospital (POS 22). Received 2026-07-11.

Denied

Billed

$11,265.00

3 lines

Allowed

$6,195.75

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Victoria Graham
Member ID: UHC-99148-14
Date of birth: 1950-09-24
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-425001
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-0617
Coverage period: 2024-05-01 to 2026-04-12
Deductible: $757.62 of $1,000.0076%
Out-of-pocket maximum: $773.94 of $2,000.0039%
Copays: office $40.00, specialist $50.00, emergency $350.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 6545828207
Network: In network
Rendering NPI: 9823058547
Location: Miami, FL · TIN 98-4961021
Authorisation / referral: PA2026085426 / REF426982

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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$3,300.00	$1,815.00	—	—	DeniedCO27
2	73721 rev 0610	MRI lower extremity joint without contrast	—	1	2	$2,266.00	$1,246.30	—	—	DeniedCO27
3	29881 rev 0360	Knee arthroscopy with meniscectomy	—	1	1	$5,699.00	$3,134.45	—	—	DeniedCO27
Totals						$11,265.00	$6,195.75	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter

Claim header

Patient account: PA-929471
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-015066 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-06-17 is after coverage terminated on 2026-04-12. Expenses incurred after coverage terminated
Timely filing	Pass		Received 24 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026085426 on file for 70553, 73721, 29881.
Provider network	Pass		In-network provider Northgate Orthopedic Specialists (6545828207).
Medical necessity	Review	CO50	70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Orthopedic Specialists2026-06-17 12:11
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-07-11 05:53
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-11 16:33
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2026085426_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-17 to 2026-09-15.
Itemized billitemized_PA-929471.pdf5 pages
Itemised statement totalling $11265.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-06-17 is after coverage terminated on 2026-04-12. Medical necessity: 70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-012430	2026-08-17	Pinecrest Family Practice	$506.00	Denied
CLM-2026-030976	2026-01-25	Sunrise Digestive Health Center	$228.00	Needs review

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity