CLM-2026-007235
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2026-09-12 at outpatient hospital (POS 22). Received 2026-10-01.
Member
Resolved through the identity graph
- Member
- Patricia Vasquez
- Member ID
- UHC-55742-93
- Date of birth
- 1975-08-25
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416319
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5391
- Coverage period
- 2024-06-01 to present
- Deductible
- $2,311.87 of $3,500.0066%
- Out-of-pocket maximum
- $5,263.56 of $14,000.0038%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 3090693813
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2026079848 / 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 | $1,482.00 | $815.10 | $815.10 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $7,229.00 | $3,975.95 | $1,453.91 | $2,522.04 | Paid |
| Totals | $8,711.00 | $4,791.05 | $2,269.01 | $2,522.04 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-344365
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-045482 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-12: NULL (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026079848 on file for 73721, 29881. | |
| 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 Center2026-09-12 18:55
Established patient presents with other tear of medial meniscus, right knee, initial encounter; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026079848_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-12 to 2026-12-11.
- Itemized billitemized_PA-344365.pdf2 pages
Itemised statement totalling $8711.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
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.