CLM-2026-002270
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-16 at outpatient hospital (POS 22). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Doris Rice
- Member ID
- UHC-90955-10
- Date of birth
- 1964-04-25
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-424175
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3061
- Coverage period
- 2025-08-01 to 2026-05-09
- Deductible
- $188.42 of $500.0038%
- Out-of-pocket maximum
- $894.37 of $2,000.0045%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6714461483
- Network
- In network
- Rendering NPI
- 3019488857
- Location
- Austin, TX · TIN 30-9158288
- Authorisation / referral
- PA2025435713 / 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 | $8,361.00 | $4,598.55 | — | — | DeniedCO27 |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 2 | $1,208.00 | $664.40 | — | — | DeniedCO27 |
| Totals | $9,569.00 | $5,262.95 | — | — | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-555789
- 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-036564 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-16 is after coverage terminated on 2026-05-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025435713 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 Specialists2026-06-16 10:59
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-28 03:29
Attachments
Documents received with the claim
- Prior auth letterPA2025435713_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-06-16 to 2026-09-14.
- Itemized billitemized_PA-555789.pdf8 pages
Itemised statement totalling $9569.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-16 is after coverage terminated on 2026-05-09.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025991 | 2026-07-09 | Lakeside Clinical Laboratories | $2,784.00 | Denied |
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
Service after coverage termination.