CLM-2026-030046
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-03 at office (POS 11). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Ray Garza
- Member ID
- UHC-65800-71
- Date of birth
- 1963-07-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406604
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-5600
- Coverage period
- 2023-01-01 to 2026-03-22
- Deductible
- $262.89 of $500.0053%
- Out-of-pocket maximum
- $244.91 of $1,000.0024%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 4268867734
- Location
- Miami, FL · TIN 98-4961021
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $275.00 | $170.50 | — | — | DeniedCO27 |
| Totals | $275.00 | $170.50 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M25.561 Pain in right knee
- Patient account
- PA-400253
- 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-006684 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-03 is after coverage terminated on 2026-03-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 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 (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 Specialists2026-06-03 11:00
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-15 04:10
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-15 11:18
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-03 is after coverage terminated on 2026-03-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008904 | 2026-05-11 | Lakeside Medical Group | $342.00 | Denied |
| CLM-2026-021899 | 2026-01-18 | Heritage Physical Therapy | $188.00 | Denied |
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.