CLM-2026-003388
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-08-31 at office (POS 11). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Natalie Palmer
- Member ID
- none on golden record
- Date of birth
- 1973-09-04
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-402050
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-8318
- Coverage period
- 2022-02-01 to present
- Deductible
- $73.82 of $1,000.007%
- Out-of-pocket maximum
- $183.55 of $4,000.005%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 1234582884
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- none / REF286080
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 | 20610 | Joint injection, major joint | — | 1 | 1 | $261.00 | $161.82 | — | — | PendedIDQ |
| Totals | $261.00 | $161.82 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-236291
- 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 | Fail | IDQ | Member record is in open steward case CASE-004294; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-08-31: CORE-HMO (HMO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 44 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 | Pass | In-network provider Meadow Bone and Joint Center (1940746575). | |
| 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: Meadow Bone and Joint Center2026-08-31 16:31
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-004294; payment withheld until the identity is confirmed. Eligibility: Active on 2026-08-31: CORE-HMO (HMO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.