CLM-2026-015674
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-10 at office (POS 11). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Emily Lawson
- Member ID
- UHC-30773-21
- Date of birth
- 2004-08-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-426666
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5064
- Coverage period
- 2023-06-01 to 2026-03-11
- Deductible
- $130.61 of $500.0026%
- Out-of-pocket maximum
- $469.51 of $1,000.0047%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 7468092458
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- none / none
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 | $170.00 | $105.40 | — | — | DeniedCO27 |
| Totals | $170.00 | $105.40 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-770893
- 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-033970 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-10 is after coverage terminated on 2026-03-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 Specialists2026-05-10 14:46
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-07 02:07
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-07 08:09
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-10 is after coverage terminated on 2026-03-11.
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
Service after coverage termination.