CLM-2026-030145
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-07 at outpatient hospital (POS 22). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Wayne Howard
- Member ID
- UHC-15907-37
- Date of birth
- 1957-01-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431388
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7107
- Coverage period
- 2024-12-01 to 2026-04-02
- Deductible
- $208.83 of $2,500.008%
- Out-of-pocket maximum
- $1,480.36 of $7,500.0020%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6714461483
- Network
- In network
- Rendering NPI
- 7633623674
- Location
- Austin, TX · TIN 30-9158288
- Authorisation / referral
- PA2025715744 / 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 | $1,659.00 | $912.45 | — | — | DeniedCO27 |
| Totals | $1,659.00 | $912.45 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-987678
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018406 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-07 is after coverage terminated on 2026-04-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025715744 on file for 73721. | |
| Provider network | Pass | In-network provider Mesa Orthopedic Specialists (6714461483). | |
| 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 Specialists2026-05-07 12:31
Patient seen for other tear of medial meniscus, right knee, initial encounter.
- SystemSystem: Claims system2026-05-19 01:26
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-19 16:12
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025715744_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-07 to 2026-08-05.
- Itemized billitemized_PA-987678.pdf9 pages
Itemised statement totalling $1659.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-07 is after coverage terminated on 2026-04-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006903 | 2026-05-22 | Summit Reference Lab | $120.00 | Denied |
| CLM-2026-014137 | 2026-03-06 | Summit Clinical Laboratories | $2,217.00 | Needs review |
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.