CLM-2026-029091
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-13 to 2026-04-17 at inpatient hospital (POS 21). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Christian Gonzalez
- Member ID
- none on golden record
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-413584
- Relationship
- Self
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 6624717222
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- PA2025274619 / 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 | $29,747.00 | $16,360.85 | — | — | PendedN30 |
| Totals | $29,747.00 | $16,360.85 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-616828
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-04-13 to 2026-04-14
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030837 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025274619 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 $29,747.00 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 Specialists2026-04-17 13:47
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-05-15 06:34
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2025274619_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-04-13 to 2026-07-12.
- Itemized billitemized_PA-616828.pdf7 pages
Itemised statement totalling $29747.00 across 1 line.
- Medical recordrecords_PA-616828.pdf5 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. High-dollar review: Billed $29,747.00 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
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.