CLM-2026-026337
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2026-02-23 at outpatient hospital (POS 22). Received 2026-04-07.
Member
Resolved through the identity graph
- Member
- Rayomnd Mendez
- Member ID
- none on golden record
- Date of birth
- 2005-06-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420983
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 4140693670
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2025600112 / 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 | $10,510.00 | $5,780.50 | — | — | PendedN30 |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 2 | $2,249.00 | $1,236.95 | — | — | PendedN30 |
| Totals | $12,759.00 | $7,017.45 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-534269
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005126 (verified, link confidence 0.99). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025600112 on file for 29881, 73721. | |
| 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 | Review | CO16 | Documentation incomplete: “Established patient presents with low back pain, unspecified; symptoms reviewed and vitals”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Bone and Joint Center2026-02-23 10:07
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-07 03:09
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2025600112_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-23 to 2026-05-24.
- Itemized billitemized_PA-534269.pdf8 pages
Itemised statement totalling $12759.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Established patient presents with low back pain, unspecified; symptoms reviewed and vitals”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014485 | 2025-12-31 | Evergreen Counseling Center | $3,567.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.