CLM-2026-015093
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2025-09-21 at outpatient hospital (POS 22). Received 2026-04-22.
Member
Resolved through the identity graph
- Member
- Daniel Schmidt
- Member ID
- UHC-31187-24
- Date of birth
- 1942-09-14
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422251
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-6733
- Coverage period
- 2021-05-01 to present
- Deductible
- $762.66 of $1,000.0076%
- Out-of-pocket maximum
- $1,251.44 of $3,000.0042%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 8743797119
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2025640119 / 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 | $1,322.00 | $727.10 | — | — | DeniedCO29 |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 2 | $10,920.00 | $6,006.00 | — | — | DeniedCO29 |
| Totals | $12,242.00 | $6,733.10 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-357415
- 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-007628 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-21: NULL (PPO), effective 2021-05-01. | |
| Timely filing | Fail | CO29 | Received 213 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025640119 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 Center2025-09-21 11:20
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-04-22 06:38
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2025640119_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2025-09-21 to 2025-12-20.
- Itemized billitemized_PA-357415.pdf6 pages
Itemised statement totalling $12242.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 213 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027863 | 2025-12-11 | Summit Family Practice | $454.00 | Approved |
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
Received after the timely-filing limit.