CLM-2026-003968
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-11 at outpatient hospital (POS 22). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Julie Lee
- Member ID
- UHC-59108-59
- Date of birth
- 1985-06-28
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-407504
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4152
- Coverage period
- 2022-02-01 to present
- Deductible
- $140.04 of $3,500.004%
- Out-of-pocket maximum
- $5,133.69 of $14,000.0037%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 2395426887
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026986685 / 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 | $7,428.00 | $3,342.60 | — | — | DeniedCO204 |
| Totals | $7,428.00 | $3,342.60 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-326741
- 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-004797 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-11: SELECT-EPO (EPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026986685 on file for 29881. | |
| Provider network | Fail | CO204 | Billing provider 7007014674 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: Cornerstone Orthopedic Specialists2026-03-11 13:22
Follow-up for unilateral primary osteoarthritis, left knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-31 04:46
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026986685_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-11 to 2026-06-09.
- Itemized billitemized_PA-326741.pdf5 pages
Itemised statement totalling $7428.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7007014674 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.