CLM-2026-029222
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-19 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Aisha Gilbert
- Member ID
- UHC-36576-92
- Date of birth
- 1971-08-08
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-423962
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6453
- Coverage period
- 2022-09-01 to present
- Deductible
- $1,563.84 of $3,500.0045%
- Out-of-pocket maximum
- $5,659.47 of $14,000.0040%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 6578343777
- Location
- Miami, FL · TIN 98-4961021
- Authorisation / referral
- PA2025483493 / REF871063
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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,977.00 | $1,087.35 | $1,087.35 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,166.00 | $5,591.30 | $2,271.56 | $3,319.74 | Paid |
| Totals | $12,143.00 | $6,678.65 | $3,358.91 | $3,319.74 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-478691
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004252 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-19: NAVIGATE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025483493 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Northgate Orthopedic Specialists (6545828207). | |
| 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 Orthopedic Specialists2025-12-19 15:12
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025483493_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-12-19 to 2026-03-19.
- Itemized billitemized_PA-478691.pdf3 pages
Itemised statement totalling $12143.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029711 | 2026-05-24 | Cornerstone Reference Lab | $176.00 | Approved |
| CLM-2026-022111 | 2025-12-15 | Sunrise Heart Institute | $416.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.