Claims workbench/CLM-2026-017072
Institutional claim · UB-04 · Paper

CLM-2026-017072

Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-01 to 2025-12-04 at inpatient hospital (POS 21). Received 2026-01-08.

Needs review
Billed
$32,757.00
1 line
Allowed
$18,016.35
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Review
HIGH
Decided by
Nobody yet
open

Member

Resolved through the identity graph

Member
Emma Henry
Member ID
UHC-50050-99
Date of birth
1980-04-13
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-400734
Relationship
Self, Plano, TX

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-7668
Coverage period
2022-08-01 to present
Deductible
$309.82 of $1,000.0031%
Out-of-pocket maximum
$833.89 of $4,000.0021%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
7 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI
6714461483
Network
In network
Rendering NPI
5870134710
Location
Austin, TX · TIN 30-9158288
Authorisation / referral
PA2025111622 / REF877861

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
127447
rev 0360
Total knee arthroplasty—11$32,757.00$18,016.35——Review
Totals$32,757.00$18,016.35——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. M54.50 Low back pain, unspecified
  • 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
Claim header
Patient account
PA-265037
Frequency code
1 (original)
Accident
No
DRG
470
Admit / discharge
2025-12-01 to 2025-12-05
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-002407 (verified, link confidence 0.99).
EligibilityPassActive on 2025-12-01: CORE-HMO (HMO), effective 2022-08-01.
Timely filingPassReceived 35 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2025111622 on file for 27447.
Provider networkPassIn-network provider Mesa Orthopedic Specialists (6714461483).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewReviewHIGHBilled $32,757.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Billed amount above auto-pay ceiling
Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Mesa Orthopedic Specialists2025-12-04 15:20

    Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.

  • SystemSystem: Claims system2026-01-08 04:29

    Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.

Attachments

Documents received with the claim

  • Prior auth letterPA2025111622_approval.pdf2 pages

    Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-01 to 2026-03-01.

  • Itemized billitemized_PA-265037.pdf5 pages

    Itemised statement totalling $32757.00 across 1 line.

  • Medical recordrecords_PA-265037.pdf9 pages

    Discharge summary and operative report.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineReview2026-10-21 13:43
    High-dollar review: Billed $32,757.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
  2. AI recommendationApproved2026-10-21 14:15
    The claim for total knee arthroplasty is supported by the member's active coverage, in-network provider status, and prior authorisation. The clinical note and medical record confirm the medical necessity and completion of the procedure. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off. The claim is approved pending human review due to the high-dollar amount.
  3. AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · e0f940b6

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0096872026-09-29Canyon Clinical Laboratories$197.00Approved

AI recommendation

apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode

Approvedconfidence 0.95Needs examiner sign-off Validated

The claim for total knee arthroplasty is supported by the member's active coverage, in-network provider status, and prior authorisation. The clinical note and medical record confirm the medical necessity and completion of the procedure. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off. The claim is approved pending human review due to the high-dollar amount.

Evidence cited: [C][DX][L1][PRV][IDN][COV][R-identity][R-eligibility][R-timely_filing][R-duplicate][R-prior_auth][R-network][R-clinical_edit][R-ncci][R-benefit_limit][R-completeness][N1][N2][A1][A2][A3]
Latency
3,461 ms
Tokens
1,439 in / 222 out
Cost
$0.0019
Input hash e880e5cee31f190b… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record it.
Outcome
444 characters
ExaminerR. Patel (Claims Examiner II)
Will apply: approve

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

ApprovedHIGHscenario: High dollar

Above auto-pay ceiling; payable once an examiner signs off.

Review queueMember identity