CLM-2026-012507
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Diana Long
- Member ID
- UHC-77612-55
- Date of birth
- 2007-11-05
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-427357
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5500
- Coverage period
- 2023-03-01 to present
- Deductible
- $2,539.19 of $3,500.0073%
- Out-of-pocket maximum
- $2,525.21 of $7,000.0036%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 2411971114
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- PA2026718384 / REF471426
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 | $10,311.00 | $5,671.05 | $1,902.86 | $3,768.19 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,433.00 | $788.15 | $157.63 | $630.52 | Paid |
| Totals | $11,744.00 | $6,459.20 | $2,060.49 | $4,398.71 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-880518
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017489 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-06: CORE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026718384 on file for 29881, 73721. | |
| 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 Specialists2026-05-06 17:34
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026718384_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-06 to 2026-08-04.
- Itemized billitemized_PA-880518.pdf7 pages
Itemised statement totalling $11744.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.