Claims workbench/CLM-2026-014655

Institutional claim · UB-04 · Paper

CLM-2026-014655

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-02 to 2026-03-05 at inpatient hospital (POS 21). Received 2026-03-13.

Needs review

Billed

$46,290.00

1 line

Allowed

$25,459.50

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO197, HIGH

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Ashley Bowman
Member ID: UHC-55178-78
Date of birth: 1954-07-27
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-427214
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-6238
Coverage period: 2022-04-01 to present
Deductible: $37.03 of $1,500.002%
Out-of-pocket maximum: $1,443.33 of $6,000.0024%
Copays: office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7225530493
Network: In network
Rendering NPI: 3824176507
Location: Charlotte, NC · TIN 40-3118368
Authorisation / referral: PHONE-231269 / REF625049

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	27447 rev 0360	Total knee arthroplasty	—	1	1	$46,290.00	$25,459.50	—	—	Review
Totals						$46,290.00	$25,459.50	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-691882
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-03-02 to 2026-03-04
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-006518 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-03-02: NAVIGATE-HMO (HMO), effective 2022-04-01.
Timely filing	Pass		Received 8 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Review	CO197	Authorisation reference “PHONE-231269” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent
Provider network	Pass		In-network provider Northgate Orthopedic Specialists (7225530493).
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	Review	HIGH	Billed $46,290.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Orthopedic Specialists2026-03-05 15:31
Established patient presents with low back pain, unspecified; 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 system2026-03-13 06:37
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-13 14:20
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-691882.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Itemized billitemized_PA-691882.pdf2 pages
Itemised statement totalling $46290.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Prior authorisation: Authorisation reference “PHONE-231269” does not match the utilisation-management format; must be confirmed before payment. High-dollar review: Billed $46,290.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-007274	2026-06-15	Unity Primary Care Associates	$495.00	Denied
CLM-2026-002404	2026-01-30	Sunrise Cardiovascular Associates	$8,651.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity