CLM-2026-009231
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-07 at outpatient hospital (POS 22). Received 2026-08-19.
Member
Resolved through the identity graph
- Member
- Hiroshi Vazquez
- Member ID
- UHC-36775-70
- Date of birth
- 1939-07-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417231
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0895
- Coverage period
- 2021-08-01 to 2026-04-06
- Deductible
- $842.40 of $1,000.0084%
- Out-of-pocket maximum
- $230.90 of $4,000.006%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 3513016774
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2025836194 / 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 | $8,311.00 | $3,739.95 | — | — | DeniedCO27 |
| Totals | $8,311.00 | $3,739.95 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-546867
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029615 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-07 is after coverage terminated on 2026-04-06. 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 PA2025836194 on file for 29881. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Specialists2026-08-07 12:53
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-19 01:25
Attachments
Documents received with the claim
- Prior auth letterPA2025836194_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-07 to 2026-11-05.
- Itemized billitemized_PA-546867.pdf4 pages
Itemised statement totalling $8311.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-07 is after coverage terminated on 2026-04-06. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.