CLM-2026-021248
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-08-12 at outpatient hospital (POS 22). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Ethan Estrada
- Member ID
- UHC-68529-89
- Date of birth
- 1966-04-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-402516
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-1849
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,293.60 of $1,500.0086%
- Out-of-pocket maximum
- $23.51 of $3,000.001%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 9061440373
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2025884419 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,972.00 | $1,634.60 | — | — | Review |
| Totals | $2,972.00 | $1,634.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-407063
- 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-007062 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-12: N/A (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025884419 on file for 70553. | |
| Provider network | Pass | In-network provider Mesa Bone and Joint Center (5449704472). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-08-12 14:59
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-08-29 04:21
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2025884419_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-12 to 2026-11-10.
- Itemized billitemized_PA-407063.pdf7 pages
Itemised statement totalling $2972.00 across 1 line.
- Medical recordrecords_PA-407063.pdf11 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013044 | 2026-02-01 | Riverside Primary Care Associates | $188.00 | Denied |
| CLM-2026-033557 | 2026-01-11 | Cornerstone Reference Lab | $51.00 | Approved |
| CLM-2026-010384 | 2026-01-04 | Cornerstone Bone and Joint Center | $229.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Notes document medical necessity.