CLM-2026-025407
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-04-23 at outpatient hospital (POS 22). Received 2026-05-24.
Member
Resolved through the identity graph
- Member
- Lisa Castro
- Member ID
- UHC-96067-72
- Date of birth
- 1991-01-19
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-431513
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1625
- Coverage period
- 2025-02-01 to present
- Deductible
- $459.28 of $1,000.0046%
- Out-of-pocket maximum
- $277.85 of $3,000.009%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 5719002193
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2025506049 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $9,669.00 | $5,317.95 | $1,496.17 | $3,821.78 | Paid |
| Totals | $9,669.00 | $5,317.95 | $1,496.17 | $3,821.78 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-469887
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010821 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-04-23: CHOICE-PLUS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025506049 on file for 29881. | |
| 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 Center2026-04-23 10:47
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025506049_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-04-23 to 2026-07-22.
- Itemized billitemized_PA-469887.pdf9 pages
Itemised statement totalling $9669.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030297 | 2026-07-21 | Canyon GI Associates | $2,069.00 | Approved |
| CLM-2026-033419 | 2026-05-09 | Canyon Skin Care Associates | $430.00 | Approved |
| CLM-2026-033367 | 2026-01-14 | Harbor Medical Group | $317.00 | Approved |
| CLM-2026-002982 | 2026-01-19 | Heritage Community Hospital | $762.00 | Approved |
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.