CLM-2026-027191
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-28 to 2025-12-29 at inpatient hospital (POS 21). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Arthur Cole
- Member ID
- UHC-98978-15
- Date of birth
- 2001-05-02
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-405864
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9447
- Coverage period
- 2022-06-01 to present
- Deductible
- $858.67 of $1,500.0057%
- Out-of-pocket maximum
- $2,193.48 of $4,500.0049%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 2655096750
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- PA2025344914 / 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 | $48,431.00 | $26,637.05 | — | — | Review |
| Totals | $48,431.00 | $26,637.05 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-526027
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-28 to 2025-12-29
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003112 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-28: NULL (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025344914 on file for 27447. | |
| Provider network | Pass | In-network provider Riverside Orthopedic Specialists (4209374246). | |
| 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 $48,431.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Orthopedic Specialists2025-12-29 09:17
Patient seen for unilateral primary osteoarthritis, left knee. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-10 06:35
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2025344914_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-28 to 2026-03-28.
- Itemized billitemized_PA-526027.pdf2 pages
Itemised statement totalling $48431.00 across 1 line.
- Medical recordrecords_PA-526027.pdf18 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44High-dollar review: Billed $48,431.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-23 17:08The claim for a total knee arthroplasty is supported by the diagnosis of unilateral primary osteoarthritis, left knee [DX]. The procedure was performed by an in-network provider [PRV], and the member is eligible for coverage [IDN, COV]. The claim has passed all deterministic rules checks [R-identity, R-eligibility, R-timely_filing, R-duplicate, R-prior_auth, R-network, R-clinical_edit, R-ncci, R-benefit_limit, R-completeness]. The billed amount exceeds the auto-adjudication ceiling [R-high_dollar], requiring examiner sign-off. The clinical note and attachments support the medical necessity and completion of the procedure [N1, A1, A3]. The confidence in this decision is high due to the comprehensive evidence supporting the claim.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:43 · 64e12670
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 17:08 · dc3c8a16
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024840 | 2026-02-13 | Cornerstone Digestive Health Center | $2,375.00 | Denied |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for a total knee arthroplasty is supported by the diagnosis of unilateral primary osteoarthritis, left knee [DX]. The procedure was performed by an in-network provider [PRV], and the member is eligible for coverage [IDN, COV]. The claim has passed all deterministic rules checks [R-identity, R-eligibility, R-timely_filing, R-duplicate, R-prior_auth, R-network, R-clinical_edit, R-ncci, R-benefit_limit, R-completeness]. The billed amount exceeds the auto-adjudication ceiling [R-high_dollar], requiring examiner sign-off. The clinical note and attachments support the medical necessity and completion of the procedure [N1, A1, A3]. The confidence in this decision is high due to the comprehensive evidence supporting the claim.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Above auto-pay ceiling; payable once an examiner signs off.