Claims workbench/CLM-2026-032086

Professional claim · CMS-1500 · EDI 837P

CLM-2026-032086

Riverside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-13 at office (POS 11). Received 2026-01-22.

DeniedOut of network

Billed

$436.00

2 lines

Allowed

$196.20

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Julie Rios
Member ID: UHC-27625-41
Date of birth: 1994-08-06
Identity: Verified4 records, confidence 0.96
Claim record: CLMCLM-415916
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-5825
Coverage period: 2024-06-01 to present
Deductible: $160.43 of $1,500.0011%
Out-of-pocket maximum: $54.63 of $3,000.002%
Copays: office $40.00, specialist $60.00, emergency $150.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 3024134405
Network: Out of network
Rendering NPI: 5782027713
Location: Scottsdale, AZ · TIN 60-0197648
Authorisation / referral: none / REF190881

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	59	1	1	$166.00	$74.70	—	—	DeniedCO204
2	20610	Joint injection, major joint	59	1	1,2	$270.00	$121.50	—	—	DeniedCO204
Totals						$436.00	$196.20	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-791391
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-006583 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-12-13: NAVIGATE-HMO (HMO), effective 2024-06-01.
Timely filing	Pass		Received 40 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)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Bone and Joint Center2025-12-13 18:46
Patient seen for low back pain, unspecified.
SystemSystem: Claims system2026-01-22 01:26
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-22 16:56
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 3024134405 is out of network and the HMO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-026200	2026-05-28	Harbor Primary Care Associates	$457.00	Denied
CLM-2026-013684	2025-12-15	Sunrise Community Hospital	$1,073.00	Denied

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity