CLM-2026-007608
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-10 at outpatient hospital (POS 22). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Kimberly Vazquez
- Member ID
- UHC-88315-80
- Date of birth
- 1971-03-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402063
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9152
- Coverage period
- 2025-07-01 to present
- Deductible
- $121.95 of $1,000.0012%
- Out-of-pocket maximum
- $1,167.61 of $4,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 3669601353
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026247895 / 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 | $1,119.00 | $503.55 | $503.55 | $0.00 | Paid |
| Totals | $1,119.00 | $503.55 | $503.55 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-177223
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-043824 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-10: N/A (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026247895 on file for 73721. | |
| 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 Specialists2026-09-10 11:47
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026247895_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-10 to 2026-12-09.
- Itemized billitemized_PA-177223.pdf4 pages
Itemised statement totalling $1119.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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
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.