CLM-2026-010587
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-10 at outpatient hospital (POS 22). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Ryan Richards
- Member ID
- UHC-91216-27
- Date of birth
- 1980-05-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408098
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5107
- Coverage period
- 2024-05-01 to present
- Deductible
- $765.10 of $1,500.0051%
- Out-of-pocket maximum
- $164.44 of $3,000.005%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3024134405
- Network
- Out of network
- Rendering NPI
- 7223281230
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- none / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,803.00 | $3,961.35 | — | — | DeniedCO197 |
| Totals | $8,803.00 | $3,961.35 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-561298
- 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-011076 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-10: NULL (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Bone and Joint Center2026-08-10 16:01
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-10 06:23
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-10 16:30
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-561298.pdf4 pages
Itemised statement totalling $8803.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 require precertification; no authorisation number on the claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009616 | 2026-01-24 | Riverside Community Hospital | $2,964.00 | Needs review |
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
Precertification required and absent.