CLM-2026-014383
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-27 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- George Garza
- Member ID
- UHC-68572-14
- Date of birth
- 1954-05-23
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419857
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2024-08-01 to present
- Deductible
- $480.64 of $3,500.0014%
- Out-of-pocket maximum
- $5,649.10 of $14,000.0040%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 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
- 3598692960
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- PA2025787428 / REF977383
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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,543.00 | $694.35 | — | — | DeniedCO204 |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | 25 | 1 | 1 | $10,672.00 | $4,802.40 | — | — | DeniedCO204 |
| Totals | $12,215.00 | $5,496.75 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-492238
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026830 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-27: CORE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025787428 on file for 73721, 29881. | |
| Provider network | Fail | CO204 | Billing provider 3024134405 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Center2026-05-27 16:16
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-06-12 04:08
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025787428_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-27 to 2026-08-25.
- Itemized billitemized_PA-492238.pdf5 pages
Itemised statement totalling $12215.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3024134405 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.