CLM-2026-029140
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-04-16 at outpatient hospital (POS 22). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Amanda Johnson
- Member ID
- UHC-06364-64
- Date of birth
- 1946-07-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-425937
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6622
- Coverage period
- 2022-07-01 to present
- Deductible
- $1,975.32 of $3,500.0056%
- Out-of-pocket maximum
- $2,743.99 of $7,000.0039%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 1154162337
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- PA2025675075 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,105.00 | $1,157.75 | $1,157.75 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1,2 | $10,666.00 | $5,866.30 | $916.87 | $4,949.43 | Paid |
| Totals | $12,771.00 | $7,024.05 | $2,074.62 | $4,949.43 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-873416
- 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-009469 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-16: - (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025675075 on file for 73721, 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 Center2026-04-16 18:16
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025675075_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-04-16 to 2026-07-15.
- Itemized billitemized_PA-873416.pdf3 pages
Itemised statement totalling $12771.00 across 2 lines.
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-2026-029033 | 2026-03-18 | Cornerstone Diabetes Center | $544.00 | Approved |
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.