Claims workbench/CLM-2026-026726

Institutional claim · UB-04 · EDI 837I

CLM-2026-026726

Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-08-28 at outpatient hospital (POS 22). Received 2026-09-30.

DeniedOut of network

Billed

$7,693.00

1 line

Allowed

$3,461.85

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Mary Daniels
Member ID: UHC-02753-64
Date of birth: 1969-09-15
Identity: Verified5 records, confidence 1.00
Claim record: CLMCLM-403192
Relationship: Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-2080
Coverage period: 2025-09-01 to present
Deductible: $1,680.85 of $3,500.0048%
Out-of-pocket maximum: $1,980.79 of $7,000.0028%
Copays: office $25.00, specialist $75.00, emergency $150.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 1493585297
Network: Out of network
Rendering NPI: 5955780692
Location: Dallas, TX · TIN 17-2392567
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	29881 rev 0360	Knee arthroscopy with meniscectomy	—	1	1	$7,693.00	$3,461.85	—	—	DeniedCO197
Totals						$7,693.00	$3,461.85	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee
3. M25.561 Pain in right knee

Claim header

Patient account: PA-250198
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-005813 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-08-28: OPTIONS-PPO (PPO), effective 2025-09-01.
Timely filing	Pass		Received 33 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	29881 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	Pass		Within the auto-adjudication 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: Northgate Bone and Joint Center2026-08-28 09:43
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-09-30 05:36
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.

Attachments

Documents received with the claim

Itemized billitemized_PA-250198.pdf4 pages
Itemised statement totalling $7693.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 29881 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.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-010058	2026-05-02	Mesa Dermatology Clinic	$190.00	Approved

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