CLM-2026-031820
Meadow Bone and Joint Center, Orthopedic Surgery. Service 2026-06-08 to 2026-06-11 at inpatient hospital (POS 21). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Frances Morales
- Member ID
- UHC-02273-82
- Date of birth
- 1946-02-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427494
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7995
- Coverage period
- 2023-10-01 to 2026-05-25
- Deductible
- $540.29 of $1,000.0054%
- Out-of-pocket maximum
- $12.12 of $2,000.001%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1940746575
- Network
- In network
- Rendering NPI
- 9123893171
- Location
- Dallas, TX · TIN 28-0561840
- Authorisation / referral
- PA2025647304 / 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 | $48,824.00 | $26,853.20 | — | — | DeniedCO27 |
| Totals | $48,824.00 | $26,853.20 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-833794
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-06-08 to 2026-06-09
- 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-037217 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-08 is after coverage terminated on 2026-05-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025647304 on file for 27447. | |
| 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 | Review | HIGH | Billed $48,824.00 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: Meadow Bone and Joint Center2026-06-11 17:58
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-04 05:39
Attachments
Documents received with the claim
- Prior auth letterPA2025647304_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-06-08 to 2026-09-06.
- Itemized billitemized_PA-833794.pdf2 pages
Itemised statement totalling $48824.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-08 is after coverage terminated on 2026-05-25. High-dollar review: Billed $48,824.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
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.