Professional claim · CMS-1500 · EDI 837P
CLM-2026-019311
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-10 at office (POS 11). Received 2026-03-14.
ApprovedOut of network
Billed
$421.00
2 lines
Allowed
$189.45
contract rate applied
Plan pays
$114.45
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Teresa Gonzales
- Member ID
- UHC-82828-61
- Date of birth
- 1961-04-23
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-410684
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6303
- Coverage period
- 2024-09-01 to present
- Deductible
- $48.82 of $3,500.001%
- Out-of-pocket maximum
- $2,069.68 of $7,000.0030%
- Copays
- office $30.00, specialist $75.00, 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
- 8222417445
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $188.00 | $84.60 | $75.00 | $9.60 | Paid |
| 2 | 20610 | Joint injection, major joint | — | 1 | 1,2 | $233.00 | $104.85 | $0.00 | $104.85 | Paid |
| Totals | $421.00 | $189.45 | $75.00 | $114.45 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-921046
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019692 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-02-10: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2026-02-10 12:38
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$421.00
Plan discount
$231.55
out-of-network allowance
Plan paid
$114.45
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033035 | 2026-03-21 | Meadow Imaging Center | $1,576.00 | Approved |
| CLM-2026-019312 | 2026-02-10 | Mesa Orthopedic Specialists | $421.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.