CLM-2026-014331
Cornerstone Imaging Center, Radiology. Service 2025-12-13 at outpatient hospital (POS 22). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Helen Gordon
- Member ID
- UHC-94111-71
- Date of birth
- 1948-02-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428357
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1065
- Coverage period
- 2023-09-01 to present
- Deductible
- $808.13 of $1,000.0081%
- Out-of-pocket maximum
- $1,057.80 of $4,000.0026%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $287.00 | $157.85 | $157.85 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $585.00 | $321.75 | $91.57 | $230.18 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1,2 | $186.00 | $102.30 | $20.46 | $81.84 | Paid |
| Totals | $1,058.00 | $581.90 | $269.88 | $312.02 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-694548
- 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-001529 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: MEDICARE-ADV-A (MA), effective 2023-09-01. | |
| 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 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 Center2025-12-13 09:21
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-694548.pdf2 pages
Itemised statement totalling $1058.00 across 3 lines.
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-2026-022626 | 2026-09-17 | Meadow Bone and Joint Center | $205.00 | 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.