CLM-2026-026762
Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-09-20 at office (POS 11). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Timothy Soto
- Member ID
- UHC-93230-87
- Date of birth
- 2005-11-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405557
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5881
- Coverage period
- 2021-11-01 to present
- Deductible
- $21.07 of $1,500.001%
- Out-of-pocket maximum
- $155.26 of $4,500.003%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 3663256295
- Location
- Mesa, AZ · TIN 68-9887889
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $296.00 | $133.20 | — | — | DeniedCO204 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $173.00 | $77.85 | — | — | DeniedCO204 |
| Totals | $469.00 | $211.05 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-883231
- 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-021973 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-20: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 9793653152 is out of network and the EPO 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: Valley Bone and Joint Center2026-09-20 14:29
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-10-16 00:03
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-16 08:07
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 9793653152 is out of network and the EPO 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.