CLM-2026-029989
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-06 to 2025-12-08 at inpatient hospital (POS 21). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Marilyn Fisher
- Member ID
- UHC-53466-53
- Date of birth
- 1985-04-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405458
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5589
- Coverage period
- 2021-12-01 to present
- Deductible
- $2,318.41 of $3,500.0066%
- Out-of-pocket maximum
- $237.27 of $7,000.003%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 9910854980
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2026294411 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $49,523.00 | $22,285.35 | — | — | Review |
| Totals | $49,523.00 | $22,285.35 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- 3. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-841007
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-06 to 2025-12-09
- 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-000077 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-06: - (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026294411 on file for 27447. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 | Review | HIGH | Billed $49,523.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2025-12-08 11:54
Patient seen for pain in right knee. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-01 00:14
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2026294411_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-06 to 2026-03-06.
- Itemized billitemized_PA-841007.pdf7 pages
Itemised statement totalling $49523.00 across 1 line.
- Medical recordrecords_PA-841007.pdf5 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $49,523.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-21 14:05The claim for a total knee arthroplasty is supported by the member's active coverage, timely filing, and prior authorization. The provider is out-of-network, but the service is covered under the member's plan. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off. The clinical note and discharge summary support the medical necessity of the procedure. The claim is approved pending human review due to the high-dollar amount.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · de3ba2b1
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for a total knee arthroplasty is supported by the member's active coverage, timely filing, and prior authorization. The provider is out-of-network, but the service is covered under the member's plan. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off. The clinical note and discharge summary support the medical necessity of the procedure. The claim is approved pending human review due to the high-dollar amount.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Above auto-pay ceiling; payable once an examiner signs off.