CLM-2026-033523
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-08-11.
Member
Resolved through the identity graph
- Member
- Keith Phillips
- Member ID
- UHC-67866-78
- Date of birth
- 1947-06-23
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-415826
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3824
- Coverage period
- 2025-03-01 to present
- Deductible
- $668.74 of $1,500.0045%
- Out-of-pocket maximum
- $754.08 of $3,000.0025%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 1639526866
- Network
- Out of network
- Rendering NPI
- 3696502475
- Location
- Miami, FL · TIN 37-8454876
- Authorisation / referral
- PA2026602748 / 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 | $2,391.00 | $1,075.95 | — | — | DeniedCO204 |
| Totals | $2,391.00 | $1,075.95 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-423330
- 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-008436 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-08-06: SELECT-EPO (EPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026602748 on file for 73721. | |
| Provider network | Fail | CO204 | Billing provider 1639526866 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Specialists2026-08-06 10:33
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-11 03:49
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-11 10:22
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026602748_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-08-06 to 2026-11-04.
- Itemized billitemized_PA-423330.pdf8 pages
Itemised statement totalling $2391.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 1639526866 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.