CLM-2026-024652
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-02-27 at outpatient hospital (POS 22). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- Evelyn Gomez
- Member ID
- UHC-57767-40
- Date of birth
- 1964-11-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404238
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6313
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,782.63 of $3,500.0051%
- Out-of-pocket maximum
- $742.03 of $14,000.005%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 1863179150
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2025207558 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,342.00 | $1,288.10 | $1,288.10 | $0.00 | Paid |
| Totals | $2,342.00 | $1,288.10 | $1,288.10 | $0.00 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-996383
- 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-024805 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-27: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025207558 on file for 73721. | |
| 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 Center2026-02-27 09:17
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025207558_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-02-27 to 2026-05-28.
- Itemized billitemized_PA-996383.pdf5 pages
Itemised statement totalling $2342.00 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-2026-015691 | 2026-08-26 | Pinecrest Heart Institute | $327.00 | 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.