CLM-2026-013956
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-03-05 at outpatient hospital (POS 22). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Ruth Webb
- Member ID
- UHC-49889-56
- Date of birth
- 1952-05-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402469
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-1127
- Coverage period
- 2025-12-01 to present
- Deductible
- $284.19 of $1,000.0028%
- Out-of-pocket maximum
- $1,330.16 of $3,000.0044%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 9742666552
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2025155377 / 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 | $10,520.00 | $5,786.00 | $2,236.87 | $3,549.13 | Paid |
| Totals | $10,520.00 | $5,786.00 | $2,236.87 | $3,549.13 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-170555
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015080 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-05: N/A (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025155377 on file for 29881. | |
| 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 Center2026-03-05 10:15
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025155377_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-05 to 2026-06-03.
- Itemized billitemized_PA-170555.pdf3 pages
Itemised statement totalling $10520.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016706 | 2026-06-02 | Canyon Reference Lab | $171.00 | Approved |
| CLM-2026-012419 | 2026-06-11 | Cornerstone Internal Medicine Associates | $198.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.