CLM-2026-023643
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-04-10 at outpatient hospital (POS 22). Received 2026-04-24.
Member
Resolved through the identity graph
- Member
- Abigail Hill
- Member ID
- UHC-84222-34
- Date of birth
- 1992-09-20
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-411638
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6695
- Coverage period
- 2025-06-01 to 2026-03-04
- Deductible
- $94.74 of $1,500.006%
- Out-of-pocket maximum
- $818.51 of $3,000.0027%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- 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
- 5241634539
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2025315436 / REF718515
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 | $5,748.00 | $3,161.40 | — | — | DeniedCO27 |
| Totals | $5,748.00 | $3,161.40 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-256713
- 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-001555 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-10 is after coverage terminated on 2026-03-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025315436 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 Center2026-04-10 17:07
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-04-24 03:07
Attachments
Documents received with the claim
- Prior auth letterPA2025315436_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-10 to 2026-07-09.
- Itemized billitemized_PA-256713.pdf5 pages
Itemised statement totalling $5748.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-10 is after coverage terminated on 2026-03-04.
Other claims for this member
Same resolved identity
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
Service after coverage termination.