CLM-2026-031367
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2026-06-08 at office (POS 11). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Julie Morgan
- Member ID
- UHC-84290-64
- Date of birth
- 1969-02-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403880
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7532
- Coverage period
- 2022-01-01 to 2026-06-10
- Deductible
- $1,174.87 of $2,500.0047%
- Out-of-pocket maximum
- $1,200.24 of $7,500.0016%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 3024134405
- Network
- Out of network
- Rendering NPI
- 7147932850
- Location
- Scottsdale, AZ · TIN 60-0197648
- Authorisation / referral
- none / REF813387
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 | $200.00 | $90.00 | — | — | DeniedCO204 |
| Totals | $200.00 | $90.00 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-788619
- 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-026748 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-08: CORE-HMO (HMO), effective 2022-01-01, terms 2026-06-10. | |
| Timely filing | Pass | Received 18 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 | Fail | CO204 | Billing provider 3024134405 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: Riverside Bone and Joint Center2026-06-08 13:26
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-26 00:56
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-26 10:36
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3024134405 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012724 | 2026-04-15 | Unity Internal Medicine Associates | $212.00 | 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
No out-of-network benefit on this plan.