CLM-2026-021984
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-02 at outpatient hospital (POS 22). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Heather Pierce
- Member ID
- UHC-29304-05
- Date of birth
- 1976-03-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412969
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7081
- Coverage period
- 2021-05-01 to present
- Deductible
- $321.09 of $2,500.0013%
- Out-of-pocket maximum
- $823.79 of $10,000.008%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 8429966632
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- PA2026920677 / 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 | $1,868.00 | $1,027.40 | — | — | PendedIDQ |
| Totals | $1,868.00 | $1,027.40 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-543136
- 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 | Fail | IDQ | Member record is in open steward case CASE-003649; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-03-02: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026920677 on file for 73721. | |
| 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 Specialists2026-03-02 16:00
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026920677_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-02 to 2026-05-31.
- Itemized billitemized_PA-543136.pdf3 pages
Itemised statement totalling $1868.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003649; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.