CLM-2026-008059
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-03-20 at outpatient hospital (POS 22). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Charlotte Gordon
- Member ID
- UHC-38994-50
- Date of birth
- 1942-12-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-416091
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5124
- Coverage period
- 2022-08-01 to present
- Deductible
- $258.27 of $500.0052%
- Out-of-pocket maximum
- $413.22 of $1,500.0028%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 3139083802
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- none / REF230725
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 | $9,848.00 | $5,416.40 | — | — | DeniedCO197 |
| Totals | $9,848.00 | $5,416.40 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-159307
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028987 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-20: NAVIGATE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Mesa Bone and Joint Center (5449704472). | |
| 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 Bone and Joint Center2026-03-20 14:53
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-05-03 00:19
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-159307.pdf7 pages
Itemised statement totalling $9848.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 29881 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013475 | 2026-08-21 | Lakeside Reference Lab | $118.00 | 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
Precertification required and absent.