CLM-2026-016478
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-06-15 at outpatient hospital (POS 22). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Betty Williamson
- Member ID
- UHC-78528-57
- Date of birth
- 2006-04-21
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408284
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9215
- Coverage period
- 2021-07-01 to present
- Deductible
- $834.41 of $2,500.0033%
- Out-of-pocket maximum
- $4,734.19 of $10,000.0047%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 2287336202
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- PA2026908069 / 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 | $10,522.00 | $5,787.10 | $2,902.04 | $2,885.06 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | 25 | 1 | 2 | $1,878.00 | $1,032.90 | $309.87 | $723.03 | Paid |
| Totals | $12,400.00 | $6,820.00 | $3,211.91 | $3,608.09 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-743473
- 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-014606 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-15: SELECT-EPO (EPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026908069 on file for 29881, 73721. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Bone and Joint Center2026-06-15 15:01
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026908069_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-06-15 to 2026-09-13.
- Itemized billitemized_PA-743473.pdf8 pages
Itemised statement totalling $12400.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006908 | 2026-06-04 | Meadow Regional Medical Center | $3,594.00 | Needs review |
| CLM-2026-029360 | 2026-01-22 | Northgate Medical Group | $309.00 | Approved |
| CLM-2026-030353 | 2026-01-27 | Valley Community Hospital | $3,415.00 | Needs review |
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.