CLM-2026-032942
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-12 at outpatient hospital (POS 22). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Jessica Burns
- Member ID
- UHC-28147-73
- Date of birth
- 2007-05-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403425
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8822
- Coverage period
- 2022-01-01 to present
- Deductible
- $956.91 of $3,500.0027%
- Out-of-pocket maximum
- $1,960.33 of $10,500.0019%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 7124102840
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2025668203 / 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 | $1,462.00 | $657.90 | $657.90 | $0.00 | Paid |
| Totals | $1,462.00 | $657.90 | $657.90 | $0.00 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-928028
- 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-001963 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-12: OPTIONS-PPO (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025668203 on file for 73721. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Orthopedic Specialists2026-06-12 10:35
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025668203_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-06-12 to 2026-09-10.
- Itemized billitemized_PA-928028.pdf2 pages
Itemised statement totalling $1462.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015638 | 2025-09-23 | Harbor Medical Group | $562.00 | Denied |
| CLM-2026-013804 | 2026-03-29 | Northgate Reference Lab | $163.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.