CLM-2026-025885
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-02 at office (POS 11). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Carolyn Martin
- Member ID
- UHC-41069-52
- Date of birth
- 1986-03-17
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-423403
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1893
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,621.91 of $2,500.0065%
- Out-of-pocket maximum
- $1,002.88 of $10,000.0010%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 2466690551
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- none / REF144352
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $192.00 | $86.40 | — | — | DeniedCO204 |
| Totals | $192.00 | $86.40 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-880963
- 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-025239 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-02: NAVIGATE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 42 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 | 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2026-07-02 17:19
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-08-13 06:25
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1639526866 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007266 | 2026-08-18 | Harbor Primary Care Associates | $534.00 | Denied |
| CLM-2026-007265 | 2026-08-18 | Harbor Primary Care Associates | $534.00 | Approved |
| CLM-2026-027843 | 2026-05-29 | Canyon Community Hospital | $2,153.00 | Needs review |
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.