CLM-2026-007710
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2025-12-07 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Sophia Hunt
- Member ID
- UHC-36645-75
- Date of birth
- 1997-11-18
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-425254
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6401
- Coverage period
- 2021-07-01 to present
- Deductible
- $702.99 of $3,500.0020%
- Out-of-pocket maximum
- $1,649.40 of $7,000.0024%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 8541435599
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- none / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,283.00 | $705.65 | — | — | DeniedCO197 |
| Totals | $1,283.00 | $705.65 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-610358
- 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-005512 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-07: UNKNOWN (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2025-12-07 14:37
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-01-18 01:50
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-610358.pdf9 pages
Itemised statement totalling $1283.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 73721 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023577 | 2026-08-26 | Valley Family Practice | $24.00 | Approved |
| CLM-2026-024053 | 2026-06-23 | Northgate Primary Care Associates | $602.00 | Approved |
| CLM-2026-013855 | 2026-04-19 | Summit Endocrine Associates | $259.00 | Denied |
| CLM-2026-013854 | 2026-04-19 | Summit Endocrine Associates | $259.00 | Approved |
| CLM-2026-029413 | 2025-12-26 | Heritage Behavioral Health | $2,154.00 | Needs review |
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.