Professional claim · CMS-1500 · EDI 837P
CLM-2026-013279
Cornerstone Diabetes Center, Endocrinology. Service 2026-01-10 at office (POS 11). Received 2026-02-16.
Approved
Billed
$530.00
2 lines
Allowed
$328.60
contract rate applied
Plan pays
$253.60
approved
Member owes
$75.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Lauren Hansen
- Member ID
- UHC-05841-17
- Date of birth
- 1979-04-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-400358
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4291
- Coverage period
- 2021-09-01 to present
- Deductible
- $2,305.12 of $3,500.0066%
- Out-of-pocket maximum
- $6,122.54 of $14,000.0044%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4170744542
- Network
- In network
- Rendering NPI
- 3577686967
- Location
- Dallas, TX · TIN 78-1267454
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $358.00 | $221.96 | $75.00 | $146.96 | Paid |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 2 | $172.00 | $106.64 | $0.00 | $106.64 | Paid |
| Totals | $530.00 | $328.60 | $75.00 | $253.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-975280
- 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-013464 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-10: CHOICE-PLUS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 37 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 Diabetes Center (4170744542). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Diabetes Center2026-01-10 11:19
Patient seen for hypothyroidism, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$530.00
Plan discount
$201.40
contracted rate
Plan paid
$253.60
You may owe
$75.00
copay, deductible and coinsurance
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-2026-013280 | 2026-01-10 | Cornerstone Diabetes Center | $530.00 | Denied |
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.