CLM-2026-019767
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-01-23 at outpatient hospital (POS 22). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Amanda Larson
- Member ID
- UHC-40234-04
- Date of birth
- 1948-12-20
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-408704
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8548
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,692.74 of $3,500.0048%
- Out-of-pocket maximum
- $2,021.34 of $7,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 7960044353
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- PA2025904229 / REF465927
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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,071.00 | $1,139.05 | $1,139.05 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | 25 | 1 | 2 | $7,618.00 | $4,189.90 | $1,020.38 | $3,169.52 | Paid |
| Totals | $9,689.00 | $5,328.95 | $2,159.43 | $3,169.52 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-476104
- 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-014970 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-23: CORE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025904229 on file for 73721, 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 Center2026-01-23 12:52
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025904229_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-01-23 to 2026-04-23.
- Itemized billitemized_PA-476104.pdf6 pages
Itemised statement totalling $9689.00 across 2 lines.
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
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.