Claims workbench/CLM-2026-026561

Institutional claim · UB-04 · Paper

CLM-2026-026561

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-22 to 2025-12-25 at inpatient hospital (POS 21). Received 2026-01-01.

DeniedOut of network

Billed

$42,438.00

1 line

Allowed

$19,097.10

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Ethan Jackson
Member ID: UHC-62313-89
Date of birth: 1954-04-10
Identity: Verified6 records, confidence 0.96
Claim record: CLMCLM-421894
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-7394
Coverage period: 2021-04-01 to present
Deductible: $680.60 of $1,500.0045%
Out-of-pocket maximum: $2,778.34 of $6,000.0046%
Copays: office $25.00, specialist $50.00, emergency $250.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3024134405
Network: Out of network
Rendering NPI: 2186498475
Location: Scottsdale, AZ · TIN 60-0197648
Authorisation / referral: none / 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	27447 rev 0360	Total knee arthroplasty	—	1	1	$42,438.00	$19,097.10	—	—	DeniedCO197
Totals						$42,438.00	$19,097.10	—	—

Diagnoses (ICD-10-CM)

1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
2. M25.561 Pain in right knee
3. M17.11 Unilateral primary osteoarthritis, right knee

Claim header

Patient account: PA-385100
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2025-12-22 to 2025-12-26
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-000104 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-12-22: UNKNOWN (PPO), effective 2021-04-01.
Timely filing	Pass		Received 7 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	27447 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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	Review	HIGH	Billed $42,438.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2025-12-25 16:59
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-01-01 01:51
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-01 10:37
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-385100.pdf8 pages
Itemised statement totalling $42438.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 27447 require precertification; no authorisation number on the claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $42,438.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023449	2026-09-04	Unity Primary Care Associates	$201.00	Approved
CLM-2026-012780	2026-03-29	Evergreen Orthopedic Specialists	$28,146.00	Needs review

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity