Professional claim · CMS-1500 · Paper
CLM-2026-028479
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-10-01 at office (POS 11). Received 2026-10-12.
Approved
Billed
$465.00
2 lines
Allowed
$288.30
contract rate applied
Plan pays
$238.30
approved
Member owes
$50.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Patricia Carpenter
- Member ID
- UHC-50496-96
- Date of birth
- 1953-12-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409251
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8011
- Coverage period
- 2024-07-01 to present
- Deductible
- $245.50 of $500.0049%
- Out-of-pocket maximum
- $315.02 of $1,000.0032%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7225530493
- Network
- In network
- Rendering NPI
- 1057598975
- Location
- Charlotte, NC · TIN 40-3118368
- 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 | $179.00 | $110.98 | $50.00 | $60.98 | Paid |
| 2 | 20610 | Joint injection, major joint | 25 | 1 | 1 | $286.00 | $177.32 | $0.00 | $177.32 | Paid |
| Totals | $465.00 | $288.30 | $50.00 | $238.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
Claim header
- Patient account
- PA-954668
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011435 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-01: OPTIONS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 11 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 | Pass | In-network provider Northgate Orthopedic Specialists (7225530493). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Orthopedic Specialists2026-10-01 10:30
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$465.00
Plan discount
$176.70
contracted rate
Plan paid
$238.30
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025149 | 2026-03-11 | Northgate Counseling Center | $423.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.