Claims workbench/CLM-2026-022126
Institutional claim · UB-04 · EDI 837I

CLM-2026-022126

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-17 at outpatient hospital (POS 22). Received 2026-01-25.

Pended
Billed
$10,643.00
1 line
Allowed
$5,853.65
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Lauren Franklin
Member ID
none on golden record
Date of birth
1961-08-23
Identity
Verified3 records, confidence 0.98
Claim record
CLMCLM-425406
Relationship
Child, Jacksonville, FL

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI
7225530493
Network
In network
Rendering NPI
1713747164
Location
Charlotte, NC · TIN 40-3118368
Authorisation / referral
PA2026771510 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
129881
rev 0360
Knee arthroscopy with meniscectomy—11$10,643.00$5,853.65——PendedN30
Totals$10,643.00$5,853.65——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
Claim header
Patient account
PA-765698
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

CheckResultCodeDetail
Member identityPassAttached to MBR-007457 (verified, link confidence 0.98).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 8 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026771510 on file for 29881.
Provider networkPassIn-network provider Northgate Orthopedic Specialists (7225530493).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Northgate Orthopedic Specialists2026-01-17 18:07

    Follow-up for pain in right knee. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Prior auth letterPA2026771510_approval.pdf2 pages

    Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-17 to 2026-04-17.

  • Itemized billitemized_PA-765698.pdf6 pages

    Itemised statement totalling $10643.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

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

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity