Claims workbench/CLM-2026-026841

Institutional claim · UB-04 · EDI 837I

CLM-2026-026841

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-21 to 2025-12-23 at inpatient hospital (POS 21). Received 2026-02-01.

Needs reviewOut of network

Billed

$51,733.00

1 line

Allowed

$23,279.85

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

DUP, HIGH

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Michelle Elliott
Member ID: UHC-58397-47
Date of birth: 1945-01-28
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-424184
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-5806
Coverage period: 2022-02-01 to present
Deductible: $814.66 of $3,500.0023%
Out-of-pocket maximum: $4,589.66 of $10,500.0044%
Copays: office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits: 15 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: 6835128284
Location: Scottsdale, AZ · TIN 60-0197648
Authorisation / referral: PA2025095489 / 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	$51,733.00	$23,279.85	—	—	Review
Totals						$51,733.00	$23,279.85	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-137522
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2025-12-21 to 2025-12-23
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-003892 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-21: UNKNOWN (PPO), effective 2022-02-01.
Timely filing	Pass		Received 40 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-026840, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2025095489 on file for 27447.
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 $51,733.00 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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2025-12-23 10:58
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-02-01 05:10
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-01 09:10
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025095489_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-21 to 2026-03-21.
Itemized billitemized_PA-137522.pdf8 pages
Itemised statement totalling $51733.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-026840, billed by a different provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $51,733.00 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-2026-021397	2026-09-06	Desert Medical Group	$490.00	Approved
CLM-2026-004514	2026-01-10	Desert Medical Group	$335.00	Needs review
CLM-2026-026840	2025-12-21	Riverside Orthopedic Specialists	$51,733.00	Needs review
CLM-2026-004513	2026-01-10	Desert Medical Group	$335.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity