CLM-2026-031139
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Oar Espinoza
- Member ID
- UHC-79522-74
- Date of birth
- 1972-06-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424020
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8719
- Coverage period
- 2024-09-01 to present
- Deductible
- $445.01 of $500.0089%
- Out-of-pocket maximum
- $225.24 of $1,500.0015%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1493585297
- Network
- Out of network
- Rendering NPI
- 9259722699
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- PA2026815191 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $6,261.00 | $2,817.45 | — | — | DeniedCO204 |
| Totals | $6,261.00 | $2,817.45 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-252533
- 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-015145 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-13: CORE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026815191 on file for 29881. | |
| Provider network | Fail | CO204 | Billing provider 1493585297 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Bone and Joint Center2026-02-13 14:30
Patient seen for unilateral primary osteoarthritis, right knee.
- SystemSystem: Claims system2026-02-22 05:00
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026815191_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-13 to 2026-05-14.
- Itemized billitemized_PA-252533.pdf3 pages
Itemised statement totalling $6261.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 1493585297 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.