Claims workbench/CLM-2026-020547

Institutional claim · UB-04 · EDI 837I

CLM-2026-020547

Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2025-09-21 to 2025-09-23 at inpatient hospital (POS 21). Received 2026-04-24.

DeniedOut of network

Billed

$37,830.00

1 line

Allowed

$17,023.50

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Omar Pena
Member ID: UHC-29214-87
Date of birth: 1945-10-04
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-428788
Relationship: Spouse, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-1128
Coverage period: 2022-06-01 to present
Deductible: $770.63 of $3,500.0022%
Out-of-pocket maximum: $5,363.01 of $14,000.0038%
Copays: office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Mesa Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 1639526866
Network: Out of network
Rendering NPI: 4284500855
Location: Miami, FL · TIN 37-8454876
Authorisation / referral: PA2025980381 / 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	27447 rev 0360	Total knee arthroplasty	—	1	1	$37,830.00	$17,023.50	—	—	DeniedCO29
Totals						$37,830.00	$17,023.50	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter

Claim header

Patient account: PA-911771
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2025-09-21 to 2025-09-23
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-027533 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-09-21: CHOICE-PLUS-PPO (PPO), effective 2022-06-01.
Timely filing	Fail	CO29	Received 213 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		Authorisation PA2025980381 on file for 27447.
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	Review	HIGH	Billed $37,830.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Mesa Orthopedic Specialists2025-09-23 18:37
Patient seen for unilateral primary osteoarthritis, right knee.
SystemSystem: Claims system2026-04-24 01:48
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-24 09:30
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025980381_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-09-21 to 2025-12-20.
Itemized billitemized_PA-911771.pdf3 pages
Itemised statement totalling $37830.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 213 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $37,830.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity