CLM-2026-018242
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-03 at outpatient hospital (POS 22). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Edward Alvarado
- Member ID
- none on golden record
- Date of birth
- 1960-06-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425622
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- N/A PPO group GRP-3935
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,590.66 of $3,500.0045%
- Out-of-pocket maximum
- $1,577.08 of $7,000.0023%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 7672474468
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2025430390 / 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 | $6,396.00 | $2,878.20 | — | — | PendedIDQ |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,309.00 | $589.05 | — | — | PendedIDQ |
| Totals | $7,705.00 | $3,467.25 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-578074
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001697; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-02-03: N/A (PPO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025430390 on file for 29881, 73721. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Orthopedic Specialists2026-02-03 14:29
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025430390_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-03 to 2026-05-04.
- Itemized billitemized_PA-578074.pdf6 pages
Itemised statement totalling $7705.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001697; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-03: N/A (PPO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.