CLM-2026-000546
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-04 at outpatient hospital (POS 22). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Amy Morrison
- Member ID
- UHC-29243-33
- Date of birth
- 1977-02-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-429122
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1225
- Coverage period
- 2024-09-01 to present
- Deductible
- $577.91 of $3,500.0017%
- Out-of-pocket maximum
- $3,157.61 of $7,000.0045%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6714461483
- Network
- In network
- Rendering NPI
- 2852522350
- Location
- Austin, TX · TIN 30-9158288
- Authorisation / referral
- PA2026684660 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,211.00 | $5,616.05 | $3,191.49 | $2,424.56 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,088.00 | $1,148.40 | $114.84 | $1,033.56 | Paid |
| Totals | $12,299.00 | $6,764.45 | $3,306.33 | $3,458.12 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-516230
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026412 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-04: OPTIONS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026684660 on file for 29881, 73721. | |
| Provider network | Pass | In-network provider Mesa Orthopedic Specialists (6714461483). | |
| 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: Mesa Orthopedic Specialists2026-05-04 13:46
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026684660_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-04 to 2026-08-02.
- Itemized billitemized_PA-516230.pdf3 pages
Itemised statement totalling $12299.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.