CLM-2026-008949
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-08 at outpatient hospital (POS 22). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Isabella Ferguson
- Member ID
- none on golden record
- Date of birth
- 1995-12-16
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-425954
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-7664
- Coverage period
- 2022-08-01 to present
- Deductible
- $595.35 of $1,500.0040%
- Out-of-pocket maximum
- $400.46 of $6,000.007%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 4066772128
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- PA2025775127 / REF525119
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 | $2,044.00 | $1,124.20 | $926.61 | $197.59 | Paid |
| Totals | $2,044.00 | $1,124.20 | $926.61 | $197.59 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-733338
- 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-016733 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-02-08: CORE-HMO (HMO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025775127 on file for 73721. | |
| 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 Specialists2026-02-08 10:45
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025775127_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-02-08 to 2026-05-09.
- Itemized billitemized_PA-733338.pdf3 pages
Itemised statement totalling $2044.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-02-08: CORE-HMO (HMO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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.