CLM-2026-019638
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-01-12 at office (POS 11). Received 2026-08-11.
Member
Resolved through the identity graph
- Member
- Michelle Henry
- Member ID
- UHC-04410-99
- Date of birth
- 1947-05-10
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-430873
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7107
- Coverage period
- 2024-09-01 to present
- Deductible
- $103.85 of $1,500.007%
- Out-of-pocket maximum
- $111.89 of $3,000.004%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 1182859557
- Location
- Minneapolis, MN · TIN 26-9111057
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $286.00 | $177.32 | — | — | DeniedCO29 |
| Totals | $286.00 | $177.32 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-508496
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029161 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-12: CHOICE-PLUS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Fail | CO29 | Received 211 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Bone and Joint Center (5449704472). | |
| 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 Bone and Joint Center2026-01-12 14:17
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-08-11 04:03
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-11 09:26
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 211 days after the last date of service (limit 90).
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
Received after the timely-filing limit.