CLM-2026-033688
Riverside Bone and Joint Center, Orthopedic Surgery. Service 2025-12-07 at outpatient hospital (POS 22). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Christopher Johnson
- Member ID
- none on golden record
- Date of birth
- 1938-01-19
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-417676
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Riverside Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5897697269
- Network
- In network
- Rendering NPI
- 7016488349
- Location
- San Diego, CA · TIN 43-7655262
- Authorisation / referral
- none / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,177.00 | $647.35 | — | — | DeniedCO197 |
| Totals | $1,177.00 | $647.35 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-194050
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001212 (verified, 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 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Riverside Bone and Joint Center (5897697269). | |
| 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 Center2025-12-07 10:25
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-04 01:43
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-04 14:32
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-194050.pdf2 pages
Itemised statement totalling $1177.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. Prior authorisation: 73721 require precertification; no authorisation number on the claim.
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
Precertification required and absent.