CLM-2026-023736
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-03 at outpatient hospital (POS 22). Received 2026-05-10.
Member
Resolved through the identity graph
- Member
- Kelly Contreras
- Member ID
- UHC-65136-03
- Date of birth
- 1992-03-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415962
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8407
- Coverage period
- 2023-04-01 to present
- Deductible
- $707.21 of $1,000.0071%
- Out-of-pocket maximum
- $828.67 of $4,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7225530493
- Network
- In network
- Rendering NPI
- 4848119820
- Location
- Charlotte, NC · TIN 40-3118368
- Authorisation / referral
- PA2026968882 / 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 | $8,153.00 | $4,484.15 | $1,550.20 | $2,933.95 | Paid |
| Totals | $8,153.00 | $4,484.15 | $1,550.20 | $2,933.95 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-466194
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019716 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-03: MEDICARE-ADV-B (MA), effective 2023-04-01. | |
| 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 PA2026968882 on file for 29881. | |
| Provider network | Pass | In-network provider Northgate Orthopedic Specialists (7225530493). | |
| 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: Northgate Orthopedic Specialists2026-04-03 12:53
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026968882_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-03 to 2026-07-02.
- Itemized billitemized_PA-466194.pdf2 pages
Itemised statement totalling $8153.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013973 | 2026-02-26 | Lakeside Endocrine Associates | $379.00 | 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.