CLM-2026-020639
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-09 at office (POS 11). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Michelle Gutierrez
- Member ID
- UHC-39357-75
- Date of birth
- 1979-03-25
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-415371
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-8321
- Coverage period
- 2024-03-01 to present
- Deductible
- $19.48 of $500.004%
- Out-of-pocket maximum
- $589.84 of $1,500.0039%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 7621480681
- Location
- Miami, FL · TIN 51-8195966
- 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 | $75.00 | $30.40 | Paid |
| Totals | $170.00 | $105.40 | $75.00 | $30.40 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-165622
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024269 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-09: - (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 4 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 Riverside Orthopedic Specialists (4209374246). | |
| 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 Orthopedic Specialists2026-07-09 13:57
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006644 | 2026-03-08 | Pinecrest GI Associates | $315.00 | Denied |
| CLM-2026-006643 | 2026-03-08 | Pinecrest GI Associates | $315.00 | 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.