CLM-2026-014735
Cornerstone Diabetes Center, Endocrinology. Service 2026-03-22 at office (POS 11). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Nicholas West
- Member ID
- UHC-15259-45
- Date of birth
- 1984-01-12
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-427857
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9386
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,226.23 of $1,500.0082%
- Out-of-pocket maximum
- $856.43 of $6,000.0014%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4170744542
- Network
- In network
- Rendering NPI
- 5394155530
- Location
- Dallas, TX · TIN 78-1267454
- Authorisation / referral
- none / REF398255
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $268.00 | $166.16 | $75.00 | $91.16 | Paid |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 2 | $171.00 | $106.02 | $0.00 | $106.02 | Paid |
| Totals | $439.00 | $272.18 | $75.00 | $197.18 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-953534
- 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-005702 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 44 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Diabetes Center2026-03-22 18:13
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-05 00:44
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-953534.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
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
Authorisation must be confirmed with UM before payment.