CLM-2026-034255
Mesa Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-11.
Member
Resolved through the identity graph
- Member
- Kyle Sanchez
- Member ID
- UHC-85114-93
- Date of birth
- 1963-05-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409912
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2222
- Coverage period
- 2024-01-01 to present
- Deductible
- $671.42 of $1,500.0045%
- Out-of-pocket maximum
- $2,176.69 of $4,500.0048%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6714461483
- Network
- In network
- Rendering NPI
- 7213789473
- Location
- Austin, TX · TIN 30-9158288
- Authorisation / referral
- PA2026409702 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $9,343.00 | $5,138.65 | $1,690.59 | $3,448.06 | Paid |
| Totals | $9,343.00 | $5,138.65 | $1,690.59 | $3,448.06 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. M54.50 Low back pain, unspecified
- 3. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-636372
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016437 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-A (MA), 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 PA2026409702 on file for 29881. | |
| Provider network | Pass | In-network provider Mesa Orthopedic Specialists (6714461483). | |
| 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 Specialists2026-02-13 16:14
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026409702_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-02-13 to 2026-05-14.
- Itemized billitemized_PA-636372.pdf8 pages
Itemised statement totalling $9343.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019083 | 2026-02-09 | Sunrise Cardiovascular Associates | $700.00 | 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.