Claims workbench/CLM-2026-029178

Institutional claim · UB-04 · EDI 837I

CLM-2026-029178

Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-09-15 at outpatient hospital (POS 22). Received 2026-10-10.

Denied

Billed

$5,854.00

2 lines

Allowed

$3,219.70

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Lucia Soto
Member ID: UHC-71796-85
Date of birth: 2000-02-03
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-414966
Relationship: Spouse, Tucson, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-9925
Coverage period: 2024-01-01 to 2026-02-27
Deductible: $539.68 of $1,500.0036%
Out-of-pocket maximum: $1,680.43 of $6,000.0028%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 1940746575
Network: In network
Rendering NPI: 7608441797
Location: Dallas, TX · TIN 28-0561840
Authorisation / referral: PA2026666078 / 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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$3,514.00	$1,932.70	—	—	DeniedCO27
2	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1	$2,340.00	$1,287.00	—	—	DeniedCO27
Totals						$5,854.00	$3,219.70	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter
3. M25.561 Pain in right knee

Claim header

Patient account: PA-186369
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-002330 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-09-15 is after coverage terminated on 2026-02-27. Expenses incurred after coverage terminated
Timely filing	Pass		Received 25 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026666078 on file for 70553, 73721.
Provider network	Pass		In-network provider Meadow Bone and Joint Center (1940746575).
Medical necessity	Review	CO50	70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow Bone and Joint Center2026-09-15 14:18
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-10-10 00:38
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-10 08:53
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026666078_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-15 to 2026-12-14.
Itemized billitemized_PA-186369.pdf5 pages
Itemised statement totalling $5854.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-09-15 is after coverage terminated on 2026-02-27. Medical necessity: 70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity