CLM-2026-012839
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-01-05 at outpatient hospital (POS 22). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Jean Lynch
- Member ID
- UHC-03327-17
- Date of birth
- 1996-12-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416478
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9849
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,429.02 of $2,500.0057%
- Out-of-pocket maximum
- $1,513.87 of $5,000.0030%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 3733424790
- Location
- Minneapolis, MN · TIN 26-9111057
- 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,952.00 | $6,023.60 | — | — | DeniedCO197 |
| Totals | $10,952.00 | $6,023.60 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-584466
- 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-003997 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-05: OPTIONS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 8 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 Center2026-01-05 14:26
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-13 04:16
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-13 13:14
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-584466.pdf5 pages
Itemised statement totalling $10952.00 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
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.