CLM-2026-022173
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-22 at outpatient hospital (POS 22). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Martha Sanchez
- Member ID
- UHC-34396-45
- Date of birth
- 1992-08-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-402853
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3597
- Coverage period
- 2022-06-01 to present
- Deductible
- $48.17 of $2,500.002%
- Out-of-pocket maximum
- $4,208.00 of $10,000.0042%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 2715786911
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2026375841 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,384.00 | $622.80 | $622.80 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,890.00 | $4,900.50 | $2,136.18 | $2,764.32 | Paid |
| Totals | $12,274.00 | $5,523.30 | $2,758.98 | $2,764.32 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-704291
- 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-027829 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: NULL (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026375841 on file for 73721, 29881. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2026-03-22 13:06
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026375841_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-22 to 2026-06-20.
- Itemized billitemized_PA-704291.pdf5 pages
Itemised statement totalling $12274.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.