CLM-2026-021307
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-04-17 at outpatient hospital (POS 22). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Heather Burton
- Member ID
- UHC-19857-94
- Date of birth
- 2006-05-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414875
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group NULL
- Coverage period
- 2021-07-01 to present
- Deductible
- $366.84 of $1,500.0024%
- Out-of-pocket maximum
- $1,049.41 of $3,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1493585297
- Network
- Out of network
- Rendering NPI
- 2976481822
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2026222176 / 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 | $10,944.00 | $4,924.80 | $1,512.32 | $3,412.48 | Paid |
| Totals | $10,944.00 | $4,924.80 | $1,512.32 | $3,412.48 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-814575
- 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-030209 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-17: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026222176 on file for 29881. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Bone and Joint Center2026-04-17 14:09
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026222176_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-17 to 2026-07-16.
- Itemized billitemized_PA-814575.pdf9 pages
Itemised statement totalling $10944.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010971 | 2026-05-02 | Desert Regional Medical Center | $2,103.00 | 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.