CLM-2026-006380
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-29 to 2026-07-03 at inpatient hospital (POS 21). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Russell Tucker
- Member ID
- UHC-79982-50
- Date of birth
- 1953-03-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403212
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0155
- Coverage period
- 2024-01-01 to present
- Deductible
- $1,320.32 of $3,500.0038%
- Out-of-pocket maximum
- $2,503.96 of $10,500.0024%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 5425873424
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026084363 / REF411551
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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $45,126.00 | $20,306.70 | — | — | DeniedCO204 |
| Totals | $45,126.00 | $20,306.70 | — | — | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-975326
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-06-29 to 2026-07-03
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023479 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: NAVIGATE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 1 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026084363 on file for 27447. | |
| Provider network | Fail | CO204 | Billing provider 7007014674 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 | Review | HIGH | Billed $45,126.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Orthopedic Specialists2026-07-03 09:28
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-04 00:28
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026084363_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-06-29 to 2026-09-27.
- Itemized billitemized_PA-975326.pdf4 pages
Itemised statement totalling $45126.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 7007014674 is out of network and the HMO plan has no out-of-network benefit. High-dollar review: Billed $45,126.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
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
No out-of-network benefit on this plan.