CLM-2026-021384
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-01 to 2025-12-03 at inpatient hospital (POS 21). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Jose Mejia
- Member ID
- UHC-36493-03
- Date of birth
- 1978-12-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420116
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1847
- Coverage period
- 2023-05-01 to present
- Deductible
- $391.48 of $500.0078%
- Out-of-pocket maximum
- $296.48 of $1,000.0030%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 9336514689
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2025351451 / 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 | $34,233.00 | $15,404.85 | — | — | Review |
| Totals | $34,233.00 | $15,404.85 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-502943
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-01 to 2025-12-04
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001214 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-01: MEDICARE-ADV-A (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025351451 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 $34,233.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2025-12-03 13:30
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-04 04:10
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2025351451_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-01 to 2026-03-01.
- Itemized billitemized_PA-502943.pdf5 pages
Itemised statement totalling $34233.00 across 1 line.
- Medical recordrecords_PA-502943.pdf4 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $34,233.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-21 14:05The claim for a total knee arthroplasty is supported by the member's active coverage [COV], a valid prior authorisation [A1], and medical necessity [R-clinical_edit]. The provider is out-of-network [PRV], but the service is covered under the member's plan [R-prior_auth]. The claim is not a duplicate [R-duplicate] and was filed within the timely filing limit [R-timely_filing]. The clinical note [N1] and discharge summary [A3] confirm the procedure was completed without complication. The billed amount exceeds the auto-adjudication ceiling [R-high_dollar], requiring examiner sign-off, but the evidence supports approval.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 5d33cce8
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005024 | 2026-05-13 | Desert Internal Medicine Associates | $65.00 | Approved |
| CLM-2026-021136 | 2026-03-07 | Sunrise Clinical Laboratories | $167.00 | Needs review |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for a total knee arthroplasty is supported by the member's active coverage [COV], a valid prior authorisation [A1], and medical necessity [R-clinical_edit]. The provider is out-of-network [PRV], but the service is covered under the member's plan [R-prior_auth]. The claim is not a duplicate [R-duplicate] and was filed within the timely filing limit [R-timely_filing]. The clinical note [N1] and discharge summary [A3] confirm the procedure was completed without complication. The billed amount exceeds the auto-adjudication ceiling [R-high_dollar], requiring examiner sign-off, but the evidence supports approval.
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
Above auto-pay ceiling; payable once an examiner signs off.