Claims workbench/CLM-2026-022381

Professional claim · CMS-1500 · EDI 837P

CLM-2026-022381

Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-12-29 at office (POS 11). Received 2026-02-07.

Needs reviewReplacement of CLM-2026-022380Out of network

Billed

$151.00

1 line

Allowed

$67.95

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Stephen Ford
Member ID: UHC-14624-83
Date of birth: 1974-03-24
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-430689
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-6316
Coverage period: 2024-05-01 to present
Deductible: $2,643.51 of $3,500.0076%
Out-of-pocket maximum: $2,559.83 of $7,000.0037%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Valley Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 9793653152
Network: Out of network
Rendering NPI: 3481229219
Location: Mesa, AZ · TIN 68-9887889
Authorisation / referral: none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99213	Office visit, established patient, low complexity	—	1	1	$151.00	$67.95	—	—	Review
Totals						$151.00	$67.95	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-966867
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-006968 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-29: CHOICE-PLUS-PPO (PPO), effective 2024-05-01.
Timely filing	Pass		Received 40 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-022380; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		No line requires precertification.
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.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Bone and Joint Center2025-12-29 15:14
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-02-07 01:35
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-07 15:20
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-022380.pdf1 page
Provider cover letter requesting replacement of CLM-2026-022380.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-022380; the original must be voided when this adjudicates. 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

Claim	Service	Provider	Billed	Status
CLM-2026-019058	2026-02-22	Unity Cardiovascular Associates	$622.00	Approved
CLM-2026-022380	2025-12-29	Valley Bone and Joint Center	$151.00	Approved

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity