CLM-2026-031550
Northgate Bone and Joint Center, Orthopedic Surgery. Service 2026-02-20 at office (POS 11). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Raymond Kim
- Member ID
- UHC-89856-22
- Date of birth
- 2002-05-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415057
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8547
- Coverage period
- 2023-11-01 to present
- Deductible
- $587.50 of $2,500.0024%
- Out-of-pocket maximum
- $3,114.82 of $10,000.0031%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 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
- 8700883316
- Location
- Dallas, TX · TIN 17-2392567
- Authorisation / referral
- none / REF371644
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 | $202.00 | $90.90 | — | — | DeniedCO204 |
| Totals | $202.00 | $90.90 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-102117
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010006 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: NAVIGATE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Pass | Received 26 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 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 Center2026-02-20 11:16
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-18 06:08
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-18 16:15
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 engineDenied2026-10-21 13:43Provider 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014488 | 2026-02-25 | Canyon Diagnostic Imaging | $2,249.00 | Needs review |
| CLM-2026-027362 | 2026-03-04 | Meadow Imaging Center | $727.00 | Approved |
| CLM-2026-014487 | 2026-02-25 | Evergreen Diagnostic Imaging | $2,249.00 | Approved |
| CLM-2026-013971 | 2026-01-14 | Unity Dermatology Clinic | $213.00 | Approved |
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.