CLM-2026-021922
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-03-27 at outpatient hospital (POS 22). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Bryant Timothy
- Member ID
- none on golden record
- Date of birth
- 1980-04-17
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-432659
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- - PPO group GRP-2035
- Coverage period
- 2025-08-01 to present
- Deductible
- $86.17 of $500.0017%
- Out-of-pocket maximum
- $334.60 of $1,500.0022%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 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
- 1355613773
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- none / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,226.00 | $551.70 | — | — | DeniedCO197 |
| Totals | $1,226.00 | $551.70 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-686664
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025394 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-03-27: - (PPO), effective 2025-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-03-27 10:46
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-04-12 06:53
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-12 16:25
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-686664.pdf8 pages
Itemised statement totalling $1226.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Active on 2026-03-27: - (PPO), effective 2025-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: 73721 require precertification; no authorisation number on the claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
Precertification required and absent.