CLM-2026-014696
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-03-28 at outpatient hospital (POS 22). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Gloria Martinez
- Member ID
- UHC-12879-76
- Date of birth
- 1959-09-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-421341
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0778
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,007.62 of $2,500.0040%
- Out-of-pocket maximum
- $536.99 of $5,000.0011%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 9481922737
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2026265827 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,124.00 | $1,168.20 | $1,168.20 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | 25 | 1 | 1 | $9,198.00 | $5,058.90 | $797.65 | $4,261.25 | Paid |
| Totals | $11,322.00 | $6,227.10 | $1,965.85 | $4,261.25 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-631717
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028646 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-28: MEDICARE-ADV-B (MA), effective 2021-09-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026265827 on file for 73721, 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 Center2026-03-28 10:11
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026265827_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-28 to 2026-06-26.
- Itemized billitemized_PA-631717.pdf5 pages
Itemised statement totalling $11322.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.