Claims workbench/CLM-2026-021837

Institutional claim · UB-04 · EDI 837I

CLM-2026-021837

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-08-29.

Needs review

Billed

$7,798.00

2 lines

Allowed

$4,288.90

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO197

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Marc Matthews
Member ID: UHC-28870-27
Date of birth: 1990-03-08
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-426255
Relationship: Self, Austin, TX

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-0629
Coverage period: 2025-01-01 to present
Deductible: $2,074.51 of $2,500.0083%
Out-of-pocket maximum: $1,208.39 of $5,000.0024%
Copays: office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 5897697269
Network: In network
Rendering NPI: 8416484904
Location: San Diego, CA · TIN 43-7655262
Authorisation / referral: PHONE-508420 / 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	$6,567.00	$3,611.85	—	—	Review
2	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1	$1,231.00	$677.05	—	—	Review
Totals						$7,798.00	$4,288.90	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal

Claim header

Patient account: PA-680495
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-001395 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-24: OPTIONS-PPO (PPO), effective 2025-01-01.
Timely filing	Pass		Received 36 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Review	CO197	Authorisation reference “PHONE-508420” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent
Provider network	Pass		In-network provider Riverside Bone and Joint Center (5897697269).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2026-07-24 13:08
Patient seen for unilateral primary osteoarthritis, right knee. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-08-29 01:01
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-29 11:42
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-680495.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Itemized billitemized_PA-680495.pdf2 pages
Itemised statement totalling $7798.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Prior authorisation: Authorisation reference “PHONE-508420” does not match the utilisation-management format; must be confirmed before payment.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-002645	2025-12-10	Harbor Rehabilitation Center	$355.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity