Claims workbench/CLM-2026-025784

Institutional claim · UB-04 · EDI 837I

CLM-2026-025784

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-01-03 at outpatient hospital (POS 22). Received 2026-01-24.

Needs review

Billed

$10,571.00

1 line

Allowed

$5,814.05

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Stephen Alvarado
Member ID: UHC-69270-12
Date of birth: 1990-04-08
Identity: Verified3 records, confidence 1.00
Claim record: CLMCLM-426584
Relationship: Self, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-1715
Coverage period: 2022-04-01 to present
Deductible: $861.93 of $1,000.0086%
Out-of-pocket maximum: $1,517.97 of $4,000.0038%
Copays: office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 5897697269
Network: In network
Rendering NPI: 2795092495
Location: San Diego, CA · TIN 43-7655262
Authorisation / referral: PA2026551786 / 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	$10,571.00	$5,814.05	—	—	Review
Totals						$10,571.00	$5,814.05	—	—

Diagnoses (ICD-10-CM)

1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal

Claim header

Patient account: PA-314977
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-001966 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-01-03: OPTIONS-PPO (PPO), effective 2022-04-01.
Timely filing	Pass		Received 21 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-025783, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2026551786 on file for 29881.
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.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2026-01-03 13:35
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-01-24 01:52
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.

Attachments

Documents received with the claim

Prior auth letterPA2026551786_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-01-03 to 2026-04-03.
Itemized billitemized_PA-314977.pdf5 pages
Itemised statement totalling $10571.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Duplicate check: Same member, date of service and procedures as CLM-2026-025783, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-008621	2026-02-28	Lakeside Medical Group	$265.00	Approved
CLM-2026-025783	2026-01-03	Riverside Orthopedic Specialists	$10,571.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity