CLM-2026-027333
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-01-26 at outpatient hospital (POS 22). Received 2026-03-11.
Member
Resolved through the identity graph
- Member
- Nathan Olson
- Member ID
- UHC-91260-88
- Date of birth
- 1993-12-09
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-411860
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8684
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,982.85 of $2,500.0079%
- Out-of-pocket maximum
- $4,465.46 of $10,000.0045%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 1964926137
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- none / REF943143
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 | $10,257.00 | $5,641.35 | — | — | DeniedCO197 |
| Totals | $10,257.00 | $5,641.35 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-162248
- 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-015953 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-26: CORE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 29881 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-01-26 15:27
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-03-11 03:46
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-11 16:01
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-162248.pdf3 pages
Itemised statement totalling $10257.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 29881 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023648 | 2026-08-03 | Lakeside Physical Therapy | $224.00 | Approved |
| CLM-2026-034549 | 2026-07-31 | Riverside Community Hospital | $1,754.00 | Needs review |
| CLM-2026-021917 | 2026-01-27 | Meadow Reference Lab | $163.00 | 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.