CLM-2026-034325
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2025-11-17 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Lisa Hughes
- Member ID
- UHC-77813-26
- Date of birth
- 2005-08-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414252
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1800
- Coverage period
- 2022-01-01 to present
- Deductible
- $337.47 of $2,500.0013%
- Out-of-pocket maximum
- $1,948.12 of $5,000.0039%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7225530493
- Network
- In network
- Rendering NPI
- 8109382803
- Location
- Charlotte, NC · TIN 40-3118368
- Authorisation / referral
- none / REF627104
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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,812.00 | $5,946.60 | — | — | DeniedCO197 |
| Totals | $10,812.00 | $5,946.60 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-841412
- 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-000168 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-17: CORE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Northgate Orthopedic Specialists (7225530493). | |
| 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 Orthopedic Specialists2025-11-17 13:08
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-01 02:31
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-01 15:18
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-841412.pdf9 pages
Itemised statement totalling $10812.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 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.