CLM-2026-024959
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-15 at outpatient hospital (POS 22). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Elizabeth Martin
- Member ID
- UHC-63125-78
- Date of birth
- 1973-10-05
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-403048
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6116
- Coverage period
- 2025-12-01 to present
- Deductible
- $462.98 of $3,500.0013%
- Out-of-pocket maximum
- $2,714.75 of $10,500.0026%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6714461483
- Network
- In network
- Rendering NPI
- 8115312653
- Location
- Austin, TX · TIN 30-9158288
- Authorisation / referral
- none / REF325018
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 | $1,786.00 | $982.30 | — | — | DeniedCO197 |
| Totals | $1,786.00 | $982.30 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-753159
- 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-026386 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-15: CORE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Mesa Orthopedic Specialists (6714461483). | |
| 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 Specialists2026-07-15 16:48
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-21 00:25
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-21 14:37
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-753159.pdf5 pages
Itemised statement totalling $1786.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721 require precertification; no authorisation number on the claim.
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
Precertification required and absent.