CLM-2026-018393
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-29 to 2026-05-30 at inpatient hospital (POS 21). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Ruth Jordan
- Member ID
- UHC-15673-95
- Date of birth
- 1941-01-21
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-422471
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7672
- Coverage period
- 2021-09-01 to present
- Deductible
- $2,576.54 of $3,500.0074%
- Out-of-pocket maximum
- $1,973.53 of $10,500.0019%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 8578770496
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2025084546 / REF985568
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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $30,079.00 | $13,535.55 | — | — | DeniedCO204 |
| Totals | $30,079.00 | $13,535.55 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-496704
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-05-29 to 2026-06-01
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037632 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-29: CORE-HMO (HMO), effective 2021-09-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025084546 on file for 27447. | |
| Provider network | Fail | CO204 | Billing provider 1639526866 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 | Review | HIGH | Billed $30,079.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2026-05-30 14:45
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-07-10 01:22
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-10 11:19
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025084546_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-05-29 to 2026-08-27.
- Itemized billitemized_PA-496704.pdf5 pages
Itemised statement totalling $30079.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1639526866 is out of network and the HMO plan has no out-of-network benefit. High-dollar review: Billed $30,079.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.