CLM-2026-015969
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Evelyn Vargas
- Member ID
- UHC-34654-11
- Date of birth
- 1969-01-18
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-419420
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8730
- Coverage period
- 2024-11-01 to present
- Deductible
- $466.09 of $1,500.0031%
- Out-of-pocket maximum
- $1,442.33 of $3,000.0048%
- Copays
- office $30.00, 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
- 5897697269
- Network
- In network
- Rendering NPI
- 9696626685
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2025176669 / 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 | $7,993.00 | $4,396.15 | $1,370.13 | $3,026.02 | Paid |
| Totals | $7,993.00 | $4,396.15 | $1,370.13 | $3,026.02 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-652456
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005331 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-29: MEDICARE-ADV-A (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025176669 on file for 29881. | |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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 Center2025-12-29 15:35
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025176669_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2025-12-29 to 2026-03-29.
- Itemized billitemized_PA-652456.pdf8 pages
Itemised statement totalling $7993.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007336 | 2026-07-26 | Evergreen Dermatology Clinic | $760.00 | 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.