CLM-2026-009347
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-06 at office (POS 11). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Isabella Wilson
- Member ID
- UHC-32664-98
- Date of birth
- 2003-04-02
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-412687
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7186
- Coverage period
- 2024-12-01 to present
- Deductible
- $178.60 of $500.0036%
- Out-of-pocket maximum
- $257.73 of $1,000.0026%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 2520209174
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- none / REF588131
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $308.00 | $190.96 | — | — | DeniedCO18 |
| Totals | $308.00 | $190.96 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-850276
- 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-003684 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-06: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-009346: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Orthopedic Specialists (4209374246). | |
| 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: Riverside Orthopedic Specialists2025-12-06 15:38
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-22 05:23
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-009346: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019979 | 2026-05-27 | Sunrise Community Hospital | $1,196.00 | Needs review |
| CLM-2026-030864 | 2026-04-14 | Harbor Primary Care Associates | $333.00 | Denied |
| CLM-2026-030755 | 2026-02-07 | Evergreen Medical Group | $384.00 | Approved |
| CLM-2026-009346 | 2025-12-06 | Riverside Orthopedic Specialists | $308.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.