CLM-2026-025619
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-26 at outpatient hospital (POS 22). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Jonathan Mason
- Member ID
- UHC-16686-90
- Date of birth
- 1958-03-06
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-416461
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4363
- Coverage period
- 2021-05-01 to present
- Deductible
- $907.07 of $1,500.0060%
- Out-of-pocket maximum
- $106.66 of $3,000.004%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 3656688488
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- PA2025101597 / 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 | $2,003.00 | $1,101.65 | $745.55 | $356.10 | Paid |
| Totals | $2,003.00 | $1,101.65 | $745.55 | $356.10 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-114288
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006335 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-26: SELECT-EPO (EPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025101597 on file for 73721. | |
| Provider network | Pass | In-network provider Northgate Orthopedic Specialists (6545828207). | |
| 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 Specialists2026-02-26 11:20
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025101597_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-02-26 to 2026-05-27.
- Itemized billitemized_PA-114288.pdf7 pages
Itemised statement totalling $2003.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022753 | 2026-08-31 | Summit Diagnostic Imaging | $496.00 | Needs review |
| CLM-2026-022752 | 2026-08-31 | Desert Diagnostic Imaging | $496.00 | Approved |
| CLM-2026-027592 | 2025-12-29 | Sunrise Counseling Center | $3,165.00 | Needs review |
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.