CLM-2026-026406
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Joshua White
- Member ID
- UHC-26246-17
- Date of birth
- 1941-04-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426359
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4707
- Coverage period
- 2023-01-01 to present
- Deductible
- $592.39 of $2,500.0024%
- Out-of-pocket maximum
- $1,870.87 of $5,000.0037%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1493585297
- Network
- Out of network
- Rendering NPI
- 7013673828
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2026278733 / 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 | $8,877.00 | $3,994.65 | — | — | DeniedCO204 |
| Totals | $8,877.00 | $3,994.65 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-538248
- 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-011672 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-19: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026278733 on file for 29881. | |
| Provider network | Fail | CO204 | Billing provider 1493585297 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Bone and Joint Center2026-08-19 13:55
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-24 03:39
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-24 11:05
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026278733_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-538248.pdf6 pages
Itemised statement totalling $8877.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1493585297 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.