CLM-2026-022291
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-03 to 2026-07-04 at inpatient hospital (POS 21). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Aisha Griffin
- Member ID
- UHC-65002-81
- Date of birth
- 2005-09-04
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-405779
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6675
- Coverage period
- 2025-08-01 to present
- Deductible
- $628.74 of $2,500.0025%
- Out-of-pocket maximum
- $2,362.36 of $10,000.0024%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 7765055281
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2025530142 / REF174069
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 | $47,211.00 | $21,244.95 | — | — | DeniedCO204 |
| Totals | $47,211.00 | $21,244.95 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-181914
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-07-03 to 2026-07-04
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001130 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-03: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025530142 on file for 27447. | |
| Provider network | Fail | CO204 | Billing provider 1639526866 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 $47,211.00 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 Specialists2026-07-04 12:21
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-19 00:22
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-19 13:50
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025530142_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-07-03 to 2026-10-01.
- Itemized billitemized_PA-181914.pdf7 pages
Itemised statement totalling $47211.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 1639526866 is out of network and the HMO plan has no out-of-network benefit. High-dollar review: Billed $47,211.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.