CLM-2026-026153
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-18 at outpatient hospital (POS 22). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Christian Vargas
- Member ID
- UHC-00336-95
- Date of birth
- 1962-12-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432389
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9253
- Coverage period
- 2024-10-01 to present
- Deductible
- $1,024.06 of $2,500.0041%
- Out-of-pocket maximum
- $3,162.77 of $7,500.0042%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 3465430809
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- PHONE-149520 / 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 | $1,443.00 | $793.65 | — | — | Review |
| Totals | $1,443.00 | $793.65 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-531194
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020503 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-18: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-149520” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| 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 Specialists2026-04-18 09:54
Follow-up for pain in right knee. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-20 00:48
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-531194.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-531194.pdf5 pages
Itemised statement totalling $1443.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-149520” does not match the utilisation-management format; must be confirmed before payment.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.