CLM-2026-022307
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-02-03 at outpatient hospital (POS 22). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Sofia Andrews
- Member ID
- UHC-65628-97
- Date of birth
- 1996-02-17
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427082
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8253
- Coverage period
- 2023-02-01 to 2026-02-13
- Deductible
- $283.00 of $1,000.0028%
- Out-of-pocket maximum
- $1,183.31 of $4,000.0030%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 17 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
- 3435096342
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2025785956 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,201.00 | $1,440.45 | — | — | DeniedCO204 |
| Totals | $3,201.00 | $1,440.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-119917
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016983 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-03: SELECT-EPO (EPO), effective 2023-02-01, terms 2026-02-13. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025785956 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 1493585297 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-02-03 10:03
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-02 02:33
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-02 13:27
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025785956_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-03 to 2026-05-04.
- Itemized billitemized_PA-119917.pdf4 pages
Itemised statement totalling $3201.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1493585297 is out of network and the EPO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033257 | 2026-07-18 | Mesa Orthopedic Specialists | $211.00 | Denied |
| CLM-2026-010069 | 2026-05-06 | Northgate Internal Medicine Associates | $628.00 | Denied |
| CLM-2026-013190 | 2026-03-06 | Desert Primary Care Associates | $488.00 | Denied |
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
No out-of-network benefit on this plan.