CLM-2026-023403
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2025-10-26 at office (POS 11). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Isabella Garza
- Member ID
- UHC-80809-16
- Date of birth
- 1975-04-25
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-420321
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6958
- Coverage period
- 2022-07-01 to present
- Deductible
- $330.69 of $500.0066%
- Out-of-pocket maximum
- $971.37 of $2,000.0049%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5513308960
- Network
- In network
- Rendering NPI
- 4915451460
- Location
- Minneapolis, MN · TIN 38-7701279
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $320.00 | $198.40 | — | — | DeniedCO29 |
| Totals | $320.00 | $198.40 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-950711
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001442 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-10-26: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Fail | CO29 | Received 162 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Orthopedic Specialists (5513308960). | |
| 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 Orthopedic Specialists2025-10-26 10:02
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-04-06 02:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 162 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012612 | 2025-12-23 | Summit Clinical Laboratories | $148.00 | Approved |
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
Received after the timely-filing limit.