Professional claim · CMS-1500 · EDI 837P
CLM-2026-004632
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2025-11-27 at office (POS 11). Received 2026-01-06.
Approved
Billed
$701.00
2 lines
Allowed
$434.62
contract rate applied
Plan pays
$404.62
approved
Member owes
$30.00
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
- Elizabeth Santiago
- Member ID
- UHC-79914-44
- Date of birth
- 1974-02-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421277
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5017
- Coverage period
- 2022-06-01 to present
- Deductible
- $623.24 of $1,000.0062%
- Out-of-pocket maximum
- $852.35 of $2,000.0043%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 8914740369
- Location
- Houston, TX · TIN 58-0916222
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $286.00 | $177.32 | $30.00 | $147.32 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $415.00 | $257.30 | $0.00 | $257.30 | Paid |
| Totals | $701.00 | $434.62 | $30.00 | $404.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-123698
- 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-001902 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-27: OPTIONS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 40 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 (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. |
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 Internal Medicine Associates2025-11-27 16:21
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$701.00
Plan discount
$266.38
contracted rate
Plan paid
$404.62
You may owe
$30.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027476 | 2026-02-24 | Pinecrest Medical Group | $202.00 | Denied |
| CLM-2026-027475 | 2026-02-24 | Pinecrest Medical Group | $202.00 | Approved |
| CLM-2026-004633 | 2025-11-27 | Cornerstone Internal Medicine Associates | $701.00 | Denied |
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.