CLM-2026-024275
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-29 at office (POS 11). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Jack Ray
- Member ID
- UHC-59604-32
- Date of birth
- 1955-10-24
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-420732
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9941
- Coverage period
- 2022-02-01 to present
- Deductible
- $807.14 of $3,500.0023%
- Out-of-pocket maximum
- $746.07 of $10,500.007%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 4405772706
- Location
- Tempe, AZ · TIN 82-7144175
- Authorisation / referral
- none / REF986760
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 | $197.00 | $122.14 | — | — | DeniedCO18 |
| Totals | $197.00 | $122.14 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-854447
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017203 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-01-29: NAVIGATE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 53 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024274: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Orthopedic Specialists (4479500462). | |
| 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: Evergreen Orthopedic Specialists2026-01-29 10:44
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-23 02:46
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-23 09:48
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-024274: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018400 | 2026-07-11 | Meadow Family Practice | $336.00 | Approved |
| CLM-2026-024274 | 2026-01-29 | Evergreen Orthopedic Specialists | $197.00 | 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
Exact duplicate of an earlier submission.