CLM-2026-009194
Cornerstone Diabetes Center, Endocrinology. Service 2026-03-12 at office (POS 11). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Amber Salazar
- Member ID
- UHC-48415-05
- Date of birth
- 1995-06-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432528
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7401
- Coverage period
- 2021-02-01 to present
- Deductible
- $81.07 of $1,000.008%
- Out-of-pocket maximum
- $545.96 of $3,000.0018%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4170744542
- Network
- In network
- Rendering NPI
- 3618711386
- Location
- Dallas, TX · TIN 78-1267454
- Authorisation / referral
- none / REF454466
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 | $353.00 | $218.86 | $75.00 | $143.86 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $66.00 | $40.92 | $0.00 | $40.92 | Paid |
| Totals | $419.00 | $259.78 | $75.00 | $184.78 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-371589
- 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-019715 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-12: NAVIGATE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 2 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 Diabetes Center (4170744542). | |
| 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 Diabetes Center2026-03-12 10:48
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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.