CLM-2026-027997
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-05-17 to 2026-05-20 at inpatient hospital (POS 21). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Henry Salazar
- Member ID
- UHC-44361-63
- Date of birth
- 2006-05-10
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-422201
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2434
- Coverage period
- 2021-03-01 to 2026-02-13
- Deductible
- $2,885.35 of $3,500.0082%
- Out-of-pocket maximum
- $1,528.01 of $14,000.0011%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 8507827102
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- PA2026982402 / REF662657
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 | $51,735.00 | $28,454.25 | — | — | DeniedCO27 |
| Totals | $51,735.00 | $28,454.25 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-421406
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-05-17 to 2026-05-19
- 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-023129 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-17 is after coverage terminated on 2026-02-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026982402 on file for 27447. | |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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 $51,735.00 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 Bone and Joint Center2026-05-20 15:26
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-06-30 01:56
Attachments
Documents received with the claim
- Prior auth letterPA2026982402_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-05-17 to 2026-08-15.
- Itemized billitemized_PA-421406.pdf7 pages
Itemised statement totalling $51735.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-17 is after coverage terminated on 2026-02-13. High-dollar review: Billed $51,735.00 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
Service after coverage termination.