CLM-2026-003667
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-05 at office (POS 11). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Lori Porter
- Member ID
- UHC-02218-88
- Date of birth
- 1946-02-14
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422498
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4329
- Coverage period
- 2022-04-01 to present
- Deductible
- $143.24 of $1,500.0010%
- Out-of-pocket maximum
- $104.53 of $3,000.003%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 8904810495
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- none / none
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 | $180.00 | $81.00 | — | — | DeniedCO204 |
| Totals | $180.00 | $81.00 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-606499
- 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-007682 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-05: SELECT-EPO (EPO), effective 2022-04-01. | |
| 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 | Fail | CO204 | Billing provider 1639526866 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Specialists2026-06-05 09:07
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-07-19 04:51
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-19 14:10
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1639526866 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014351 | 2026-08-24 | Heritage Primary Care Associates | $12.00 | Approved |
| CLM-2026-025042 | 2026-01-13 | Valley Community Hospital | $2,468.00 | Needs review |
| CLM-2026-011902 | 2025-12-19 | Heritage Family Practice | $524.00 | Approved |
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
No out-of-network benefit on this plan.