CLM-2026-015225
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2025-10-06 at office (POS 11). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Frances Hunter
- Member ID
- UHC-24427-43
- Date of birth
- 2005-04-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428337
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8987
- Coverage period
- 2021-08-01 to present
- Deductible
- $619.71 of $2,500.0025%
- Out-of-pocket maximum
- $371.40 of $5,000.007%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 6000841612
- 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 | $243.00 | $109.35 | — | — | DeniedCO29 |
| Totals | $243.00 | $109.35 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-838766
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000029; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-10-06: - (PPO), effective 2021-08-01. | |
| Timely filing | Fail | CO29 | Received 109 days after the last date of service (limit 90). Time limit for filing has expired |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Orthopedic Specialists2025-10-06 13:46
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-01-23 02:19
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000029; payment withheld until the identity is confirmed. Timely filing: Received 109 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.