CLM-2026-032646
Mesa Bone and Joint Center, Orthopedic Surgery. Service 2025-12-13 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Camila Rios
- Member ID
- UHC-12493-59
- Date of birth
- 1963-11-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429150
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1346
- Coverage period
- 2024-01-01 to present
- Deductible
- $813.93 of $1,000.0081%
- Out-of-pocket maximum
- $889.76 of $2,000.0044%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5449704472
- Network
- In network
- Rendering NPI
- 7567981700
- Location
- Minneapolis, MN · TIN 26-9111057
- Authorisation / referral
- PA2026334802 / REF211181
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 | $2,658.00 | $1,461.90 | — | — | Review |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,206.00 | $663.30 | — | — | Review |
| Totals | $3,864.00 | $2,125.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-709805
- 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-002324 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026334802 on file for 70553, 73721. | |
| Provider network | Pass | In-network provider Mesa Bone and Joint Center (5449704472). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Bone and Joint Center2025-12-13 16:44
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-01-08 00:16
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026334802_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-13 to 2026-03-13.
- Itemized billitemized_PA-709805.pdf9 pages
Itemised statement totalling $3864.00 across 2 lines.
- Medical recordrecords_PA-709805.pdf9 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationApproved2026-10-21 14:15The claim has passed all deterministic rules checks except for the medical necessity flag, which is supported by the clinical note [N1] and medical record [A3]. The billed amount is below the auto-pay ceiling, and the provider is in-network. The prior authorisation [A1] is valid and matches the services billed. The claim is for advanced imaging with a routine examination diagnosis, but the clinical note documents failed conservative treatment and progressive symptoms, which supports medical necessity.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 444a2d1a
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000147 | 2026-03-18 | Mesa Internal Medicine Associates | $371.00 | Denied |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim has passed all deterministic rules checks except for the medical necessity flag, which is supported by the clinical note [N1] and medical record [A3]. The billed amount is below the auto-pay ceiling, and the provider is in-network. The prior authorisation [A1] is valid and matches the services billed. The claim is for advanced imaging with a routine examination diagnosis, but the clinical note documents failed conservative treatment and progressive symptoms, which supports medical necessity.
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
Notes document medical necessity.