CLM-2026-006728
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-12 at outpatient hospital (POS 22). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Amber Castro
- Member ID
- UHC-44493-17
- Date of birth
- 1997-08-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-412521
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group -
- Coverage period
- 2021-04-01 to present
- Deductible
- $317.21 of $1,000.0032%
- Out-of-pocket maximum
- $1,364.90 of $4,000.0034%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 8948900955
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- none / none
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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $2,115.00 | $951.75 | — | — | DeniedCO197 |
| Totals | $2,115.00 | $951.75 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-804842
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-004853 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-12: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 73721 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Orthopedic Specialists2026-05-12 09:41
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-05-28 05:38
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-28 10:49
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-804842.pdf9 pages
Itemised statement totalling $2115.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 73721 require precertification; no authorisation number on the claim. Provider 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
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.