CLM-2026-009820
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2026-03-31 at outpatient hospital (POS 22). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Walter Weber
- Member ID
- UHC-22039-25
- Date of birth
- 1988-01-16
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-408258
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7396
- Coverage period
- 2022-04-01 to present
- Deductible
- $15.74 of $500.003%
- Out-of-pocket maximum
- $809.47 of $2,000.0040%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 9519999764
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2026747834 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,142.00 | $5,578.10 | — | — | DeniedCO29 |
| Totals | $10,142.00 | $5,578.10 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-619742
- 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-039445 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-03-31: - (PPO), effective 2022-04-01. | |
| Timely filing | Fail | CO29 | Received 192 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026747834 on file for 29881. | |
| Provider network | Pass | In-network provider Cornerstone Bone and Joint Center (7661667833). | |
| 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 Bone and Joint Center2026-03-31 13:57
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-10-09 04:34
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-09 09:36
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026747834_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-31 to 2026-06-29.
- Itemized billitemized_PA-619742.pdf9 pages
Itemised statement totalling $10142.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 192 days after the last date of service (limit 90).
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
Received after the timely-filing limit.