CLM-2026-012840
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-13 at outpatient hospital (POS 22). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Hannah Watson
- Member ID
- UHC-44586-69
- Date of birth
- 1995-07-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410719
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1669
- Coverage period
- 2021-03-01 to present
- Deductible
- $127.20 of $500.0025%
- Out-of-pocket maximum
- $728.60 of $1,500.0049%
- Copays
- office $40.00, specialist $75.00, 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
- 3024134405
- Network
- Out of network
- Rendering NPI
- 1647993579
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- PA2026042886 / 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 | $10,660.00 | $4,797.00 | $1,257.64 | $3,539.36 | Paid |
| Totals | $10,660.00 | $4,797.00 | $1,257.64 | $3,539.36 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-151075
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031363 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-13: CHOICE-PLUS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026042886 on file for 29881. | |
| 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 Center2026-05-13 14:55
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026042886_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-13 to 2026-08-11.
- Itemized billitemized_PA-151075.pdf7 pages
Itemised statement totalling $10660.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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-2026-029874 | 2026-08-11 | Evergreen Family Practice | $559.00 | Denied |
| CLM-2026-029873 | 2026-08-11 | Evergreen Family Practice | $559.00 | 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
Clean claim, priced at contract rate.