CLM-2026-007429
Cornerstone Family Practice, Family Medicine. Service 2025-12-19 at office (POS 11). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Edwad Vazquez
- Member ID
- UHC-56813-67
- Date of birth
- 1995-04-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-405718
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1919
- Coverage period
- 2024-10-01 to present
- Deductible
- $242.62 of $2,500.0010%
- Out-of-pocket maximum
- $1,962.18 of $7,500.0026%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6150045915
- Network
- Out of network
- Rendering NPI
- 5719741709
- Location
- Minneapolis, MN · TIN 65-3309082
- 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 | 36415 | Venipuncture | — | 1 | 1 | $19.00 | $8.55 | — | — | DeniedCO204 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $160.00 | $72.00 | — | — | DeniedCO204 |
| Totals | $179.00 | $80.55 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-364509
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003507 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-19: CORE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 6150045915 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Family Practice2025-12-19 14:32
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-01 06:47
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-01 11:26
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 6150045915 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027732 | 2025-12-03 | Heritage Clinical Laboratories | $169.00 | Approved |
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.