CLM-2026-026766
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-06-05 at outpatient hospital (POS 22). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Linda Garrett
- Member ID
- UHC-52045-15
- Date of birth
- 1947-03-01
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-402951
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6650
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,362.45 of $3,500.0039%
- Out-of-pocket maximum
- $1,300.47 of $10,500.0012%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 5604808795
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- PA2026181202 / REF752716
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 | $6,452.00 | $3,548.60 | $2,419.76 | $1,128.84 | Paid |
| Totals | $6,452.00 | $3,548.60 | $2,419.76 | $1,128.84 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-585756
- 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-001868 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-05: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026181202 on file for 29881. | |
| Provider network | Pass | In-network provider Meadow Bone and Joint Center (1940746575). | |
| 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: Meadow Bone and Joint Center2026-06-05 17:54
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026181202_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-06-05 to 2026-09-03.
- Itemized billitemized_PA-585756.pdf7 pages
Itemised statement totalling $6452.00 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-2026-005418 | 2026-06-14 | Mesa Reference Lab | $62.00 | Approved |
| CLM-2026-030815 | 2026-01-12 | Summit Primary Care Associates | $43.00 | Approved |
| CLM-2026-010169 | 2026-01-08 | Evergreen Cardiovascular Associates | $3,440.00 | Needs review |
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.