Professional claim · CMS-1500 · Provider portal
CLM-2026-010070
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-13 at office (POS 11). Received 2026-06-16.
Approved
Billed
$526.00
2 lines
Allowed
$326.12
contract rate applied
Plan pays
$286.12
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Don Richardson
- Member ID
- UHC-97967-62
- Date of birth
- 2000-06-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417567
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2877
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,578.75 of $2,500.0063%
- Out-of-pocket maximum
- $1,833.29 of $10,000.0018%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 6468565372
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- none / none
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 | $292.00 | $181.04 | $40.00 | $141.04 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $234.00 | $145.08 | $0.00 | $145.08 | Paid |
| Totals | $526.00 | $326.12 | $40.00 | $286.12 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
Claim header
- Patient account
- PA-764379
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006319 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-13: CHOICE-PLUS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Bone and Joint Center2026-05-13 11:33
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$526.00
Plan discount
$199.88
contracted rate
Plan paid
$286.12
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021558 | 2026-08-11 | Harbor Primary Care Associates | $260.00 | Denied |
| CLM-2026-021557 | 2026-08-11 | Harbor Primary Care Associates | $260.00 | Approved |
| CLM-2026-003901 | 2026-01-14 | Sunrise Cardiovascular Associates | $7,889.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.