CLM-2026-029656
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-11 at outpatient hospital (POS 22). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Madison Wilson
- Member ID
- UHC-28652-33
- Date of birth
- 2002-03-26
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-421125
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group N/A
- Coverage period
- 2023-05-01 to 2026-02-28
- Deductible
- $2,739.59 of $3,500.0078%
- Out-of-pocket maximum
- $3,109.06 of $14,000.0022%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7225530493
- Network
- In network
- Rendering NPI
- 2579355662
- Location
- Charlotte, NC · TIN 40-3118368
- Authorisation / referral
- PA2026726198 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,224.00 | $673.20 | — | — | DeniedCO27 |
| Totals | $1,224.00 | $673.20 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-674310
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030878 (provisional, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-11 is after coverage terminated on 2026-02-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026726198 on file for 73721. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Orthopedic Specialists2026-04-11 13:14
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-05-16 04:25
Attachments
Documents received with the claim
- Prior auth letterPA2026726198_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-04-11 to 2026-07-10.
- Itemized billitemized_PA-674310.pdf2 pages
Itemised statement totalling $1224.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-11 is after coverage terminated on 2026-02-28.
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.