Professional claim · CMS-1500 · Provider portal
CLM-2026-030030
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-20 at office (POS 11). Received 2026-05-05.
Approved
Billed
$432.00
2 lines
Allowed
$267.84
contract rate applied
Plan pays
$217.84
approved
Member owes
$50.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Theresa Torres
- Member ID
- UHC-55258-87
- Date of birth
- 1990-03-18
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-408202
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8404
- Coverage period
- 2024-11-01 to present
- Deductible
- $213.86 of $500.0043%
- Out-of-pocket maximum
- $475.97 of $1,500.0032%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4209374246
- Network
- In network
- Rendering NPI
- 4131844126
- Location
- Miami, FL · TIN 51-8195966
- Authorisation / referral
- none / REF224397
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 | 20610 | Joint injection, major joint | — | 1 | 1 | $241.00 | $149.42 | $50.00 | $99.42 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $191.00 | $118.42 | $0.00 | $118.42 | Paid |
| Totals | $432.00 | $267.84 | $50.00 | $217.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
Claim header
- Patient account
- PA-525225
- 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-002788 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-20: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 15 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 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 | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Orthopedic Specialists2026-04-20 09:22
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$432.00
Plan discount
$164.16
contracted rate
Plan paid
$217.84
You may owe
$50.00
copay, deductible and coinsurance
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-2026-006852 | 2026-09-22 | Northgate Internal Medicine Associates | $405.00 | Needs review |
| CLM-2026-031222 | 2026-08-08 | Heritage Rehabilitation Center | $439.00 | Approved |
| CLM-2026-026599 | 2025-12-26 | Unity Family Practice | $25.00 | Approved |
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.