CLM-2026-013196
Cornerstone Imaging Center, Radiology. Service 2026-06-18 at outpatient hospital (POS 22). Received 2026-07-30.
Member
Resolved through the identity graph
- Member
- Jacob King
- Member ID
- UHC-22406-82
- Date of birth
- 1970-03-14
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-406802
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2769
- Coverage period
- 2024-06-01 to present
- Deductible
- $361.31 of $500.0072%
- Out-of-pocket maximum
- $547.54 of $2,000.0027%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9835477198
- Network
- In network
- Rendering NPI
- 9835477198
- Location
- Tampa, FL · TIN 89-9420622
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $376.00 | $206.80 | $145.50 | $61.30 | Paid |
| Totals | $376.00 | $206.80 | $145.50 | $61.30 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-118781
- 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-001075 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-18: CHOICE-PLUS-PPO (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 42 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 Imaging Center (9835477198). | |
| 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 Imaging Center2026-06-18 14:55
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-118781.pdf8 pages
Itemised statement totalling $376.00 across 1 line.
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-2026-012740 | 2026-08-11 | Northgate Medical Group | $2,044.00 | Needs review |
| CLM-2026-013197 | 2026-06-18 | Desert Diagnostic Imaging | $376.00 | Needs review |
| CLM-2026-008454 | 2026-01-21 | Riverside Orthopedic Specialists | $301.00 | Approved |
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.