Professional claim · CMS-1500 · EDI 837P
CLM-2026-004450
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2025-11-18 at office (POS 11). Received 2026-01-01.
Approved
Billed
$426.00
2 lines
Allowed
$264.12
contract rate applied
Plan pays
$204.12
approved
Member owes
$60.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Patty Grant
- Member ID
- UHC-86096-74
- Date of birth
- 1962-11-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405076
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6535
- Coverage period
- 2025-07-01 to present
- Deductible
- $1,125.27 of $2,500.0045%
- Out-of-pocket maximum
- $3,721.48 of $7,500.0050%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 2031946215
- Location
- Tempe, AZ · TIN 28-0381608
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $213.00 | $132.06 | $60.00 | $72.06 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $213.00 | $132.06 | $0.00 | $132.06 | Paid |
| Totals | $426.00 | $264.12 | $60.00 | $204.12 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
Claim header
- Patient account
- PA-791372
- 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-000039 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-18: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 44 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 Bone and Joint Center (7661667833). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Bone and Joint Center2025-11-18 13:25
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$426.00
Plan discount
$161.88
contracted rate
Plan paid
$204.12
You may owe
$60.00
copay, deductible and coinsurance
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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.