Professional claim · CMS-1500 · EDI 837P
CLM-2026-013205
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-22 at office (POS 11). Received 2026-02-02.
ApprovedOut of network
Billed
$445.00
2 lines
Allowed
$200.25
contract rate applied
Plan pays
$125.25
approved
Member owes
$75.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Bryan Evans
- Member ID
- UHC-42432-78
- Date of birth
- 2007-08-25
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-416008
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-3137
- Coverage period
- 2022-06-01 to present
- Deductible
- $386.86 of $500.0077%
- Out-of-pocket maximum
- $530.66 of $1,500.0035%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 7995033538
- Location
- San Diego, CA · TIN 68-2977448
- 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 | 20610 | Joint injection, major joint | — | 1 | 1 | $217.00 | $97.65 | $75.00 | $22.65 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $228.00 | $102.60 | $0.00 | $102.60 | Paid |
| Totals | $445.00 | $200.25 | $75.00 | $125.25 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
Claim header
- Patient account
- PA-231516
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009753 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-22: - (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 11 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Orthopedic Specialists2026-01-22 17:42
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$445.00
Plan discount
$244.75
out-of-network allowance
Plan paid
$125.25
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.