CLM-2026-028605
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-29 at office (POS 11). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Gabriel Padilla
- Member ID
- UHC-42797-52
- Date of birth
- 2007-08-22
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-410294
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0386
- Coverage period
- 2021-05-01 to 2026-02-03
- Deductible
- $2,781.46 of $3,500.0079%
- Out-of-pocket maximum
- $1,234.63 of $7,000.0018%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 8556009636
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- none / REF990831
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 | $194.00 | $87.30 | — | — | DeniedCO27 |
| Totals | $194.00 | $87.30 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-767254
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040411 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-29 is after coverage terminated on 2026-02-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Specialists2026-08-29 15:46
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-06 02:26
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-06 12:21
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-29 is after coverage terminated on 2026-02-03. Provider 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-2026-000464 | 2026-07-09 | Unity Counseling Center | $298.00 | Denied |
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
Service after coverage termination.