Claims workbench/CLM-2026-009055

Institutional claim · UB-04 · EDI 837I

CLM-2026-009055

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-15 to 2026-04-17 at inpatient hospital (POS 21). Received 2026-05-09.

Needs review

Billed

$43,712.00

2 lines

Allowed

$24,041.60

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO97, HIGH

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Ashley Davis
Member ID: UHC-48670-60
Date of birth: 1939-01-14
Identity: Verified3 records, confidence 0.97
Claim record: CLMCLM-418696
Relationship: Child, Orlando, FL

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-1556
Coverage period: 2021-12-01 to present
Deductible: $97.28 of $3,500.003%
Out-of-pocket maximum: $1,590.01 of $10,500.0015%
Copays: office $40.00, specialist $75.00, emergency $250.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 6545828207
Network: In network
Rendering NPI: 3297092520
Location: Miami, FL · TIN 98-4961021
Authorisation / referral: PA2025325160 / 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	59	1	1	$35,215.00	$19,368.25	—	—	Review
2	29881 rev 0360	Knee arthroscopy with meniscectomy	59	1	1	$8,497.00	$4,673.35	—	—	Review
Totals						$43,712.00	$24,041.60	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter
3. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-836907
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-04-15 to 2026-04-17
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-029916 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-04-15: MEDICARE-ADV-A (MA), effective 2021-12-01.
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 PA2025325160 on file for 27447, 29881.
Provider network	Pass		In-network provider Northgate Orthopedic Specialists (6545828207).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Review	HIGH	Billed $43,712.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Orthopedic Specialists2026-04-17 16:30
Patient seen for pain in right knee. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-05-09 04:05
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Prior auth letterPA2025325160_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-04-15 to 2026-07-14.
Itemized billitemized_PA-836907.pdf4 pages
Itemised statement totalling $43712.00 across 2 lines.
Medical recordrecords_PA-836907.pdf19 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. High-dollar review: Billed $43,712.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity