CLM-2026-004237
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-05-23 to 2026-05-25 at inpatient hospital (POS 21). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Bruce Henry
- Member ID
- UHC-59684-25
- Date of birth
- 2001-02-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-400350
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9329
- Coverage period
- 2023-11-01 to 2026-06-05
- Deductible
- $883.18 of $1,000.0088%
- Out-of-pocket maximum
- $395.90 of $3,000.0013%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 8445941221
- Location
- Houston, TX · TIN 58-0916222
- Authorisation / referral
- none / 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $230.00 | $126.50 | — | — | DeniedCO18 |
| Totals | $230.00 | $126.50 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- 3. J44.9 COPD, unspecified
- Patient account
- PA-660769
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-23 to 2026-05-26
- 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-006749 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: MEDICARE-ADV-B (MA), effective 2023-11-01, terms 2026-06-05. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004236: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Cornerstone Internal Medicine Associates (1575429455). | |
| 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 Associates2026-05-25 18:42
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-07-09 05:48
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-660769.pdf2 pages
Itemised statement totalling $230.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-004236: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025032 | 2026-06-26 | Mesa Physical Therapy | $302.00 | Denied |
| CLM-2026-004236 | 2026-05-23 | Cornerstone Internal Medicine Associates | $230.00 | Approved |
| CLM-2026-020955 | 2026-01-12 | Desert Primary Care Associates | $203.00 | Denied |
| CLM-2026-020954 | 2026-01-12 | Desert Primary Care Associates | $203.00 | Approved |
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
Exact duplicate of an earlier submission.