Claims workbench/CLM-2026-014959
Professional claim · CMS-1500 · Provider portal

CLM-2026-014959

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-08-13 at office (POS 11). Received 2026-10-11.

Denied
Billed
$208.00
1 line
Allowed
$128.96
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Cunningham Omar
Member ID
UHC-84013-63
Date of birth
1942-12-28
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-403928
Relationship
Self, Jacksonville, FL

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-6654
Coverage period
2021-10-01 to present
Deductible
$194.33 of $2,500.008%
Out-of-pocket maximum
$624.78 of $5,000.0012%
Copays
office $40.00, specialist $60.00, emergency $350.00
Physical therapy visits
15 of 20 used

Provider

Billing and rendering

Billing provider
Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI
5897697269
Network
In network
Rendering NPI
9297191824
Location
San Diego, CA · TIN 43-7655262
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199213Office visit, established patient, low complexity—11$208.00$128.96——DeniedCO18
Totals$208.00$128.96——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
Patient account
PA-747542
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

CheckResultCodeDetail
Member identityPassAttached to MBR-025694 (verified, link confidence 0.99).
EligibilityPassActive on 2026-08-13: MEDICARE-ADV-B (MA), effective 2021-10-01.
Timely filingPassReceived 59 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-014958: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Bone and Joint Center (5897697269).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Riverside Bone and Joint Center2026-08-13 09:34

    Patient seen for low back pain, unspecified.

  • SystemSystem: Claims system2026-10-11 03:14

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Duplicate check: Exact duplicate of CLM-2026-014958: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0149582026-08-13Riverside Bone and Joint Center$208.00Approved

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity