CLM-2026-024454
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2025-12-29 at office (POS 11). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Larry Singh
- Member ID
- UHC-55360-97
- Date of birth
- 2004-07-15
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-426856
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5533
- Coverage period
- 2023-08-01 to present
- Deductible
- $393.04 of $3,500.0011%
- Out-of-pocket maximum
- $1,149.03 of $14,000.008%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 2904334218
- 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 | $243.00 | $150.66 | — | — | Review |
| Totals | $243.00 | $150.66 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-322114
- 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-009560 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-29: NULL (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 34 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 | Review | CO16 | Documentation incomplete: “Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; s”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Bone and Joint Center2025-12-29 15:08
Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-01 01:39
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-01 17:36
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; s”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019063 | 2026-03-24 | Sunrise Physical Therapy | $180.00 | Denied |
| CLM-2026-033751 | 2026-02-11 | Canyon Medical Group | $444.00 | 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
Development letter outstanding.