CLM-2026-031233
Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-26 at office (POS 11). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Gray Rodriguez
- Member ID
- none on golden record
- Date of birth
- 1987-10-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418017
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Heritage Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3819335712
- Network
- In network
- Rendering NPI
- 4501640690
- Location
- Tampa, FL · TIN 32-1762387
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $164.00 | $101.68 | — | — | PendedN30 |
| 2 | 20610 | Joint injection, major joint | — | 1 | 2 | $210.00 | $130.20 | — | — | PendedN30 |
| Totals | $374.00 | $231.88 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-892535
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028756 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-031232, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Orthopedic Specialists (3819335712). | |
| 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: Heritage Orthopedic Specialists2026-04-26 10:04
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-05-20 03:26
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-20 13:35
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 enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Same member, date of service and procedures as CLM-2026-031232, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031232 | 2026-04-26 | Northgate Bone and Joint Center | $374.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.