CLM-2026-016117
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-18 at office (POS 11). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Christine Brown
- Member ID
- UHC-92954-99
- Date of birth
- 1988-06-21
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-408309
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1064
- Coverage period
- 2021-11-01 to present
- Deductible
- $25.68 of $2,500.001%
- Out-of-pocket maximum
- $821.32 of $5,000.0016%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 6018828155
- 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 | 59 | 1 | 1 | $153.00 | $94.86 | — | — | Review |
| 2 | 20610 | Joint injection, major joint | 59 | 1 | 2 | $276.00 | $171.12 | — | — | Review |
| Totals | $429.00 | $265.98 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. M25.561 Pain in right knee
- Patient account
- PA-523308
- 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-001194 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-18: MEDICARE-ADV-A (MA), effective 2021-11-01. | |
| Timely filing | Pass | Received 17 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Specialists2025-12-18 09:40
Patient seen for unilateral primary osteoarthritis, left knee. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-04 02:50
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-04 16:50
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Medical recordrecords_PA-523308.pdf15 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-22 12:49The claim is for an office visit and a joint injection, both of which are supported by the diagnoses provided. The provider is in-network, and the member is eligible. The use of modifier 59 is justified by the clinical note, which documents procedures at two distinct anatomical sites. The claim is within the auto-adjudication ceiling and all required documentation is present. The NCCI edit was flagged, but the operative note confirms the use of modifier 59 is appropriate.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 0c190730
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:49 · 465da952
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020360 | 2026-06-10 | Unity Physical Therapy | $184.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an office visit and a joint injection, both of which are supported by the diagnoses provided. The provider is in-network, and the member is eligible. The use of modifier 59 is justified by the clinical note, which documents procedures at two distinct anatomical sites. The claim is within the auto-adjudication ceiling and all required documentation is present. The NCCI edit was flagged, but the operative note confirms the use of modifier 59 is appropriate.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.