CLM-2026-015185
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-02-21 at office (POS 11). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Daniel Palmer
- Member ID
- UHC-52734-93
- Date of birth
- 1960-03-08
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404054
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0160
- Coverage period
- 2022-08-01 to present
- Deductible
- $10.26 of $2,500.000%
- Out-of-pocket maximum
- $1,276.46 of $7,500.0017%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 7435129433
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 20610 | Joint injection, major joint | — | 1 | 1 | $251.00 | $155.62 | — | — | DeniedCO18 |
| Totals | $251.00 | $155.62 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-740075
- 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-012489 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-21: MEDICARE-ADV-A (MA), effective 2022-08-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-015184: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-02-21 14:01
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-23 04:05
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-015184: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007736 | 2026-07-12 | Evergreen Primary Care Associates | $282.00 | Approved |
| CLM-2026-015184 | 2026-02-21 | Mesa Bone and Joint Center | $251.00 | Approved |
| CLM-2026-022963 | 2026-01-04 | Pinecrest Medical Group | $693.00 | 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
Exact duplicate of an earlier submission.