CLM-2026-031335
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-08-08 at office (POS 11). Received 2026-08-11.
Member
Resolved through the identity graph
- Member
- Judy Burns
- Member ID
- UHC-13174-98
- Date of birth
- 1980-12-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415696
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1473
- Coverage period
- 2021-06-01 to 2026-03-17
- Deductible
- $236.20 of $1,000.0024%
- Out-of-pocket maximum
- $286.51 of $3,000.0010%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 3382110773
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- none / none
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 | 20610 | Joint injection, major joint | — | 1 | 1 | $236.00 | $146.32 | — | — | DeniedCO27 |
| Totals | $236.00 | $146.32 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-475244
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007661 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-08 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 | 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 Center2026-08-08 16:07
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-08-11 04:19
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-11 15:03
Called the provider office; awaiting documentation.
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 2026-08-08 is after coverage terminated on 2026-03-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021084 | 2026-08-13 | Pinecrest Bone and Joint Center | $9,739.00 | Denied |
| CLM-2026-018266 | 2026-03-23 | Sunrise Physical Therapy | $538.00 | Denied |
| CLM-2026-032125 | 2025-12-31 | Lakeside Digestive Health Center | $1,758.00 | Approved |
| CLM-2026-010350 | 2026-01-21 | Mesa Clinical Laboratories | $174.00 | Approved |
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.