CLM-2026-021710
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-05-11 at office (POS 11). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Michael Stewart
- Member ID
- UHC-09021-38
- Date of birth
- 1989-02-11
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-432464
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5540
- Coverage period
- 2021-08-01 to 2026-02-23
- Deductible
- $3.50 of $500.001%
- Out-of-pocket maximum
- $209.21 of $2,000.0010%
- Copays
- office $20.00, specialist $75.00, 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
- 9909516376
- 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 | $207.00 | $128.34 | — | — | DeniedCO27 |
| Totals | $207.00 | $128.34 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-690318
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017610 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-11 is after coverage terminated on 2026-02-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| 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 Center2026-05-11 17:01
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-23 02:12
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-23 14:51
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-11 is after coverage terminated on 2026-02-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005320 | 2026-05-30 | Meadow Bone and Joint Center | $10,683.00 | Denied |
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
Service after coverage termination.