CLM-2026-011250
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-03-06 at office (POS 11). Received 2026-03-12.
Member
Resolved through the identity graph
- Member
- Joe Rose
- Member ID
- UHC-80700-65
- Date of birth
- 2000-03-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413343
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3640
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,807.87 of $2,500.0072%
- Out-of-pocket maximum
- $1,439.70 of $10,000.0014%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 5608658154
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- none / REF543023
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 | $299.00 | $185.38 | $50.00 | $135.38 | Paid |
| Totals | $299.00 | $185.38 | $50.00 | $135.38 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-673905
- 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-019217 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-06: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 6 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Bone and Joint Center2026-03-06 18:17
Patient seen for pain in right knee. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-12 02:29
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-12 17:14
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-673905.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
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-2026-016954 | 2026-03-08 | Meadow Family Practice | $452.00 | Approved |
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
Authorisation must be confirmed with UM before payment.