CLM-2026-005309
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2025-11-23 at office (POS 11). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Ralph Garcia
- Member ID
- UHC-55034-74
- Date of birth
- 1945-04-22
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-430456
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4495
- Coverage period
- 2022-07-01 to present
- Deductible
- $425.00 of $1,500.0028%
- Out-of-pocket maximum
- $2,526.00 of $6,000.0042%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 4130394628
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $78.00 | $48.36 | — | — | DeniedCO29 |
| Totals | $78.00 | $48.36 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-650881
- 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-012020 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-11-23: CHOICE-PLUS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Fail | CO29 | Received 190 days after the last date of service (limit 90). Time limit for filing has expired |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Internal Medicine Associates2025-11-23 17:28
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-01 03:29
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-01 08:34
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 190 days after the last date of service (limit 90).
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
Received after the timely-filing limit.