CLM-2026-021438
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-05-04 at office (POS 11). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Diane Lewis
- Member ID
- UHC-27291-77
- Date of birth
- 2003-08-05
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420793
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1563
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,187.99 of $2,500.0048%
- Out-of-pocket maximum
- $2,291.81 of $5,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 3625535224
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- none / REF276103
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 | 20610 | Joint injection, major joint | — | 1 | 1 | $278.00 | $125.10 | — | — | DeniedCO204 |
| Totals | $278.00 | $125.10 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-623285
- 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-034970 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-04: NAVIGATE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 42 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 | Fail | CO204 | Billing provider 9793653152 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Bone and Joint Center2026-05-04 11:41
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-15 06:54
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 9793653152 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006203 | 2026-09-16 | Mesa Behavioral Health | $285.00 | Approved |
| CLM-2026-031299 | 2026-08-05 | Cornerstone Imaging Center | $2,226.00 | Approved |
| CLM-2026-032083 | 2026-08-02 | Heritage Community Hospital | $126.00 | Needs review |
| CLM-2026-032082 | 2026-08-02 | Heritage Community Hospital | $126.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.