Claims workbench/CLM-2026-022077

Institutional claim · UB-04 · EDI 837I

CLM-2026-022077

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-26 to 2026-05-30 at inpatient hospital (POS 21). Received 2026-07-02.

Needs reviewOut of network

Billed

$38,748.00

1 line

Allowed

$17,436.60

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

HIGH

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Lucia Fox
Member ID: UHC-54071-15
Date of birth: 2001-05-26
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-413864
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-2011
Coverage period: 2021-06-01 to present
Deductible: $1,072.85 of $1,500.0072%
Out-of-pocket maximum: $47.27 of $6,000.001%
Copays: office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3024134405
Network: Out of network
Rendering NPI: 4536269325
Location: Scottsdale, AZ · TIN 60-0197648
Authorisation / referral: PA2025077563 / 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	27447 rev 0360	Total knee arthroplasty	—	1	1	$38,748.00	$17,436.60	—	—	Review
Totals						$38,748.00	$17,436.60	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-432560
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-05-26 to 2026-05-28
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-037068 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-05-26: MEDICARE-ADV-A (MA), effective 2021-06-01.
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 PA2025077563 on file for 27447.
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	Review	HIGH	Billed $38,748.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-22 12:44 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 Center2026-05-30 10:32
Patient seen for unilateral primary osteoarthritis, right knee. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
SystemSystem: Claims system2026-07-02 04:32
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-02 15:32
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025077563_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-05-26 to 2026-08-24.
Itemized billitemized_PA-432560.pdf7 pages
Itemised statement totalling $38748.00 across 1 line.
Medical recordrecords_PA-432560.pdf5 pages
Discharge summary and operative report.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $38,748.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

No other claims.

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

ApprovedHIGHscenario: High dollar

Above auto-pay ceiling; payable once an examiner signs off.

Review queue Member identity