CLM-2026-002717
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-06-28 at office (POS 11). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Stephanie Rojas
- Member ID
- UHC-23206-48
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430596
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5421
- Coverage period
- 2023-09-01 to present
- Deductible
- $118.71 of $1,500.008%
- Out-of-pocket maximum
- $2,088.78 of $6,000.0035%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2306796832
- Network
- In network
- Rendering NPI
- 5365114839
- Location
- Tempe, AZ · TIN 67-7951563
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $79.00 | $48.98 | $20.00 | $28.98 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $59.00 | $36.58 | $0.00 | $36.58 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $254.00 | $157.48 | $0.00 | $157.48 | Paid |
| Totals | $392.00 | $243.04 | $20.00 | $223.04 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-547158
- 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-039625 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-28: SELECT-EPO (EPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Cornerstone Internal Medicine Associates (2306796832). | |
| 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: Cornerstone Internal Medicine Associates2026-06-28 13:56
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
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
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.