CLM-2026-022651
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-03 at outpatient hospital (POS 22). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Megan Castillo
- Member ID
- UHC-34234-24
- Date of birth
- 1955-03-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422244
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9822
- Coverage period
- 2022-05-01 to present
- Deductible
- $768.58 of $3,500.0022%
- Out-of-pocket maximum
- $234.58 of $10,500.002%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 2583058377
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2026422994 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,578.00 | $4,717.90 | $2,930.07 | $1,787.83 | Paid |
| Totals | $8,578.00 | $4,717.90 | $2,930.07 | $1,787.83 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-530288
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011315 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-03: NULL (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026422994 on file for 29881. | |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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 Bone and Joint Center2026-01-03 10:08
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2026422994_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-03 to 2026-04-03.
- Itemized billitemized_PA-530288.pdf2 pages
Itemised statement totalling $8578.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009377 | 2026-09-14 | Pinecrest Physical Therapy | $393.00 | Denied |
| CLM-2026-023420 | 2026-01-21 | Riverside Bone and Joint Center | $8,312.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.