CLM-2026-009651
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-03-02 at emergency room (POS 23). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Albert Olson
- Member ID
- UHC-39661-50
- Date of birth
- 1947-11-08
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-405475
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6202
- Coverage period
- 2022-05-01 to 2026-05-21
- Deductible
- $257.51 of $2,500.0010%
- Out-of-pocket maximum
- $3,459.83 of $7,500.0046%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1149569109
- Network
- In network
- Rendering NPI
- 1149569109
- Location
- Nashville, TN · TIN 45-8232836
- Authorisation / referral
- none / 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $152.00 | $83.60 | $83.60 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $189.00 | $103.95 | $0.00 | $103.95 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,660.00 | $913.00 | $0.00 | $913.00 | Paid |
| Totals | $2,001.00 | $1,100.55 | $83.60 | $1,016.95 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-749989
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022569 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-02: N/A (PPO), effective 2022-05-01, terms 2026-05-21. | |
| Timely filing | Pass | Received 26 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 Regional Medical Center (1149569109). | |
| 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 Regional Medical Center2026-03-02 09:46
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-749989.pdf4 pages
Itemised statement totalling $2001.00 across 3 lines.
- Er reported_report_PA-749989.pdf4 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009890 | 2026-09-16 | Valley Bone and Joint Center | $51,724.00 | Denied |
| CLM-2026-028114 | 2026-09-26 | Meadow Primary Care Associates | $12.00 | Denied |
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.