CLM-2026-013693
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2026-05-09 at outpatient hospital (POS 22). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Carol Burton
- Member ID
- UHC-89891-19
- Date of birth
- 1984-02-02
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-413887
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2024-01-01 to present
- Deductible
- $2,691.18 of $3,500.0077%
- Out-of-pocket maximum
- $3,294.70 of $7,000.0047%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 1885052864
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2025015754 / 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 | $7,711.00 | $4,241.05 | $1,838.49 | $2,402.56 | Paid |
| Totals | $7,711.00 | $4,241.05 | $1,838.49 | $2,402.56 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-779512
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020649 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-09: CHOICE-PLUS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025015754 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 Center2026-05-09 09:03
Follow-up for unilateral primary osteoarthritis, right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025015754_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-05-09 to 2026-08-07.
- Itemized billitemized_PA-779512.pdf9 pages
Itemised statement totalling $7711.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029900 | 2026-06-29 | Harbor Primary Care Associates | $246.00 | 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.