CLM-2026-006255
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2026-03-13 at outpatient hospital (POS 22). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Debra Cox
- Member ID
- UHC-62132-15
- Date of birth
- 1993-06-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-419410
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3717
- Coverage period
- 2022-10-01 to present
- Deductible
- $16.84 of $1,000.002%
- Out-of-pocket maximum
- $469.79 of $2,000.0023%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 1689339897
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2025894009 / REF721667
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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $8,982.00 | $4,940.10 | $1,378.85 | $3,561.25 | Paid |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,330.00 | $731.50 | $73.15 | $658.35 | Paid |
| Totals | $10,312.00 | $5,671.60 | $1,452.00 | $4,219.60 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-334245
- 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-019798 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-13: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025894009 on file for 29881, 73721. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Bone and Joint Center2026-03-13 09:54
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025894009_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-13 to 2026-06-11.
- Itemized billitemized_PA-334245.pdf3 pages
Itemised statement totalling $10312.00 across 2 lines.
Explanation of benefits
What the member will see
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-2026-032045 | 2026-07-18 | Canyon Cardiovascular Associates | $1,506.00 | Denied |
| CLM-2026-027968 | 2026-04-13 | Meadow GI Associates | $256.00 | Denied |
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.