CLM-2026-007639
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-08-19 at office (POS 11). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Ann Bowman
- Member ID
- UHC-58657-88
- Date of birth
- 1970-06-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428391
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3809
- Coverage period
- 2022-03-01 to 2026-05-12
- Deductible
- $2,320.67 of $3,500.0066%
- Out-of-pocket maximum
- $2,629.96 of $14,000.0019%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5055109818
- Network
- In network
- Rendering NPI
- 6275971250
- Location
- Denver, CO · TIN 34-0670860
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $345.00 | $213.90 | — | — | DeniedCO27 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $65.00 | $40.30 | — | — | DeniedCO27 |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1,2 | $69.00 | $42.78 | — | — | DeniedCO27 |
| Totals | $479.00 | $296.98 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-397378
- 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-017779 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-19 is after coverage terminated on 2026-05-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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 | Pass | In-network provider Cornerstone Internal Medicine Associates (5055109818). | |
| 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 Internal Medicine Associates2026-08-19 14:05
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-07 01:34
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-07 11:12
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-19 is after coverage terminated on 2026-05-12.
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
Service after coverage termination.