CLM-2026-024516
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2025-11-25 at office (POS 11). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Adam Taylor
- Member ID
- none on golden record
- Date of birth
- 1958-11-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-424279
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- UNKNOWN PPO group GRP-3622
- Coverage period
- 2021-01-01 to present
- Deductible
- $763.69 of $1,000.0076%
- Out-of-pocket maximum
- $161.98 of $2,000.008%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 8844708957
- 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 | $271.00 | $168.02 | — | — | DeniedCO29 |
| Totals | $271.00 | $168.02 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-246254
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002884; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-11-25: UNKNOWN (PPO), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Fail | CO29 | Received 139 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Center2025-11-25 13:21
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-13 03:23
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-002884; payment withheld until the identity is confirmed. Eligibility: Active on 2025-11-25: UNKNOWN (PPO), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 139 days after the last date of service (limit 90).
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
Received after the timely-filing limit.