CLM-2026-026286
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Kevin Scott
- Member ID
- UHC-95333-52
- Date of birth
- 1977-09-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407666
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2002
- Coverage period
- 2022-06-01 to present
- Deductible
- $67.63 of $2,500.003%
- Out-of-pocket maximum
- $2,400.17 of $10,000.0024%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 2754884759
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- PA2025644731 / 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 | $1,689.00 | $928.95 | $928.95 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 2 | $9,371.00 | $5,154.05 | $2,598.61 | $2,555.44 | Paid |
| Totals | $11,060.00 | $6,083.00 | $3,527.56 | $2,555.44 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-724480
- 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-005413 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-07: NULL (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025644731 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Riverside Orthopedic Specialists (4209374246). | |
| 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 Orthopedic Specialists2026-01-07 18:37
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025644731_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-01-07 to 2026-04-07.
- Itemized billitemized_PA-724480.pdf4 pages
Itemised statement totalling $11060.00 across 2 lines.
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-2026-002146 | 2026-10-02 | Pinecrest Diagnostic Imaging | $3,296.00 | Approved |
| CLM-2026-031075 | 2026-06-10 | Heritage Rehabilitation Center | $183.00 | Approved |
| CLM-2026-003866 | 2026-01-08 | Mesa Behavioral Health | $605.00 | 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.