CLM-2026-012550
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-10-04 at office (POS 11). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Karen Woods
- Member ID
- UHC-39950-19
- Date of birth
- 1944-07-03
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-415807
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9389
- Coverage period
- 2022-12-01 to 2026-08-26
- Deductible
- $472.70 of $1,500.0032%
- Out-of-pocket maximum
- $129.64 of $4,500.003%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2306796832
- Network
- In network
- Rendering NPI
- 8030985294
- Location
- Tempe, AZ · TIN 67-7951563
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $61.00 | $37.82 | — | — | DeniedCO27 |
| Totals | $61.00 | $37.82 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-954542
- 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-024957 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-04 is after coverage terminated on 2026-08-26. Expenses incurred after coverage terminated |
| 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 Internal Medicine Associates (2306796832). | |
| 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 Associates2026-10-04 09:02
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-06 03:39
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-04 is after coverage terminated on 2026-08-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010683 | 2026-08-12 | Mesa Physical Therapy | $355.00 | Approved |
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.