CLM-2026-018909
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-08-24 at outpatient hospital (POS 22). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Adam Morgan
- Member ID
- UHC-73274-64
- Date of birth
- 1970-12-26
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-423520
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7583
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,064.73 of $3,500.0030%
- Out-of-pocket maximum
- $2,716.03 of $7,000.0039%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 3743911547
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- PA2026619539 / 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 | $10,677.00 | $5,872.35 | $3,466.39 | $2,405.96 | Paid |
| Totals | $10,677.00 | $5,872.35 | $3,466.39 | $2,405.96 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-371987
- 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-028986 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-24: CHOICE-PLUS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026619539 on file for 29881. | |
| 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 Center2026-08-24 11:45
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026619539_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-08-24 to 2026-11-22.
- Itemized billitemized_PA-371987.pdf4 pages
Itemised statement totalling $10677.00 across 1 line.
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-2026-009239 | 2026-05-13 | Lakeside Reference Lab | $64.00 | Denied |
| CLM-2026-009238 | 2026-05-13 | Lakeside Reference Lab | $64.00 | Approved |
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.