CLM-2026-027014
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-03 at outpatient hospital (POS 22). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Ryan Soto
- Member ID
- UHC-31409-02
- Date of birth
- 2002-11-11
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-423158
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0921
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,328.24 of $3,500.0038%
- Out-of-pocket maximum
- $2,647.88 of $10,500.0025%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 1624371781
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- none / REF344091
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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,874.00 | $1,030.70 | — | — | DeniedCO197 |
| Totals | $1,874.00 | $1,030.70 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-522295
- 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-025104 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-03: NAVIGATE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Northgate Orthopedic Specialists (6545828207). | |
| 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 Orthopedic Specialists2026-03-03 11:56
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-10 06:14
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-522295.pdf8 pages
Itemised statement totalling $1874.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031291 | 2026-04-18 | Unity Digestive Health Center | $328.00 | Approved |
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
Precertification required and absent.