CLM-2026-012748
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-23 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Jack Marshall
- Member ID
- UHC-15423-91
- Date of birth
- 1963-06-13
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-404975
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8836
- Coverage period
- 2023-06-01 to present
- Deductible
- $2,941.54 of $3,500.0084%
- Out-of-pocket maximum
- $473.42 of $10,500.005%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 1158170898
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- none / REF887352
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $210.00 | $130.20 | $50.00 | $80.20 | Paid |
| 2 | 20610 | Joint injection, major joint | 25 | 1 | 2 | $264.00 | $163.68 | $0.00 | $163.68 | Paid |
| Totals | $474.00 | $293.88 | $50.00 | $243.88 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-274570
- 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-016796 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-23: NAVIGATE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 41 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 Northgate Orthopedic Specialists (6545828207). | |
| 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: Northgate Orthopedic Specialists2026-05-23 12:44
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-03 04:54
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-274570.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-2026-032177 | 2026-06-28 | Northgate Internal Medicine Associates | $190.00 | Approved |
| CLM-2026-014306 | 2026-06-11 | Northgate Cardiovascular Associates | $231.00 | Approved |
| CLM-2026-002817 | 2026-05-29 | Canyon Community Hospital | $930.00 | Needs review |
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.