CLM-2026-005305
Cornerstone Family Practice, Family Medicine. Service 2026-01-27 at office (POS 11). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Aisha Montgomery
- Member ID
- UHC-04709-66
- Date of birth
- 1941-08-14
- Identity
- Verified3 records, confidence 0.86
- Claim record
- CLMCLM-425247
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-8632
- Coverage period
- 2021-03-01 to present
- Deductible
- $2,873.97 of $3,500.0082%
- Out-of-pocket maximum
- $2,515.48 of $10,500.0024%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6150045915
- Network
- Out of network
- Rendering NPI
- 3265681379
- Location
- Minneapolis, MN · TIN 65-3309082
- 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 | 90471 | Immunization administration | — | 1 | 1 | $25.00 | $11.25 | $11.25 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $154.00 | $69.30 | $0.00 | $69.30 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $21.00 | $9.45 | $0.00 | $9.45 | Paid |
| Totals | $200.00 | $90.00 | $11.25 | $78.75 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-541707
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003261 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2026-01-27: - (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 6 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Family Practice2026-01-27 18:01
Patient seen for type 2 diabetes mellitus without complications.
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 engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.