CLM-2026-020277
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-19 to 2026-05-23 at inpatient hospital (POS 21). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Gregory Vasquez
- Member ID
- UHC-23843-06
- Date of birth
- 1949-12-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418621
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6421
- Coverage period
- 2025-04-01 to present
- Deductible
- $2,226.13 of $2,500.0089%
- Out-of-pocket maximum
- $1,553.81 of $5,000.0031%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3024134405
- Network
- Out of network
- Rendering NPI
- 8770865243
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- PA2025629524 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $28,227.00 | $12,702.15 | — | — | Review |
| Totals | $28,227.00 | $12,702.15 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-402679
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-05-19 to 2026-05-22
- 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-016601 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-19: OPTIONS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 0 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025629524 on file for 27447. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 $28,227.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Bone and Joint Center2026-05-23 09:32
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025629524_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-05-19 to 2026-08-17.
- Itemized billitemized_PA-402679.pdf7 pages
Itemised statement totalling $28227.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $28,227.00 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-2026-020278 | 2026-05-19 | Riverside Bone and Joint Center | $28,227.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Clean claim, priced at contract rate.