CLM-2026-013349
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-04-05 to 2026-04-06 at inpatient hospital (POS 21). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Bobby Castro
- Member ID
- UHC-60624-22
- Date of birth
- 1943-06-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421592
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7626
- Coverage period
- 2023-06-01 to 2026-07-13
- Deductible
- $117.48 of $1,500.008%
- Out-of-pocket maximum
- $417.99 of $3,000.0014%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 1898857440
- 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $49,754.00 | $27,364.70 | — | — | DeniedCO197 |
| Totals | $49,754.00 | $27,364.70 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-150259
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-04-05 to 2026-04-06
- 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-009179 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-05: SELECT-EPO (EPO), effective 2023-06-01, terms 2026-07-13. | |
| 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 | 27447 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 | Review | HIGH | Billed $49,754.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Bone and Joint Center2026-04-06 17:19
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-18 05:46
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-150259.pdf7 pages
Itemised statement totalling $49754.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 27447 require precertification; no authorisation number on the claim. High-dollar review: Billed $49,754.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
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.