CLM-2026-027546
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-03-27 at office (POS 11). Received 2026-04-22.
Member
Resolved through the identity graph
- Member
- Maria Delgado
- Member ID
- UHC-95248-22
- Date of birth
- 1996-06-14
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421429
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5037
- Coverage period
- 2021-03-01 to present
- Deductible
- $155.62 of $3,500.004%
- Out-of-pocket maximum
- $989.19 of $14,000.007%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1493585297
- Network
- Out of network
- Rendering NPI
- 4615671607
- Location
- Dallas, TX · TIN 17-2392567
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $153.00 | $68.85 | — | — | DeniedCO204 |
| 2 | 20610 | Joint injection, major joint | 25 | 1 | 1 | $198.00 | $89.10 | — | — | DeniedCO204 |
| Totals | $351.00 | $157.95 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-291679
- 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-001985 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-27: SELECT-EPO (EPO), effective 2021-03-01. | |
| 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 1493585297 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: Northgate Bone and Joint Center2026-03-27 18:06
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-04-22 06:37
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
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 1493585297 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.