CLM-2026-025437
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-29 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Heather Singh
- Member ID
- UHC-61064-10
- Date of birth
- 1948-01-09
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-406416
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2204
- Coverage period
- 2021-02-01 to 2026-04-21
- Deductible
- $877.48 of $1,000.0088%
- Out-of-pocket maximum
- $574.52 of $4,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3024134405
- Network
- Out of network
- Rendering NPI
- 1626784254
- Location
- Scottsdale, AZ · TIN 60-0197648
- 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 | $203.00 | $91.35 | — | — | DeniedCO27 |
| Totals | $203.00 | $91.35 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-374130
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022902 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-29 is after coverage terminated on 2026-04-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-05-29 11:47
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-04 05:59
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-04 13:11
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-29 is after coverage terminated on 2026-04-21. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023511 | 2026-07-06 | Meadow Dermatology Clinic | $552.00 | Denied |
| CLM-2026-002164 | 2026-03-03 | Riverside Medical Group | $22.00 | 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
Service after coverage termination.