CLM-2026-026265
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-07-10 at outpatient hospital (POS 22). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Jesse Kelly
- Member ID
- UHC-15221-74
- Date of birth
- 1979-05-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401356
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7503
- Coverage period
- 2024-09-01 to present
- Deductible
- $428.11 of $500.0086%
- Out-of-pocket maximum
- $814.44 of $2,000.0041%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 5799767483
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- none / REF794005
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 | $1,926.00 | $1,059.30 | — | — | DeniedCO197 |
| Totals | $1,926.00 | $1,059.30 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-644452
- 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-020206 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-10: CORE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 25 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 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 Center2026-07-10 15:09
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-04 04:45
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-04 15:54
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-644452.pdf4 pages
Itemised statement totalling $1926.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030583 | 2026-02-27 | Mesa Physical Therapy | $110.00 | Approved |
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.