CLM-2026-027695
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-24 to 2026-01-27 at inpatient hospital (POS 21). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Virginia Delgado
- Member ID
- UHC-51047-62
- Date of birth
- 1938-11-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-414291
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1495
- Coverage period
- 2023-12-01 to present
- Deductible
- $446.07 of $500.0089%
- Out-of-pocket maximum
- $508.93 of $2,000.0025%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 5913447731
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- none / 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 | $49,158.00 | $27,036.90 | — | — | DeniedCO197 |
| Totals | $49,158.00 | $27,036.90 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-342244
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-01-24 to 2026-01-28
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013367 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-24: OPTIONS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 27447 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 $49,158.00 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 Specialists2026-01-27 11:53
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-02-15 00:01
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-15 11:50
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-342244.pdf5 pages
Itemised statement totalling $49158.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $49,158.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
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
Precertification required and absent.