Claims workbench/CLM-2026-015710

Institutional claim · UB-04 · EDI 837I

CLM-2026-015710

Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-09 at outpatient hospital (POS 22). Received 2026-03-09.

DeniedOut of network

Billed

$1,182.00

1 line

Allowed

$531.90

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Adam Ortega
Member ID: UHC-52099-82
Date of birth: 2002-10-06
Identity: Verified3 records, confidence 0.96
Claim record: CLMCLM-409652
Relationship: Child, Denver, CO

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-9010
Coverage period: 2024-03-01 to present
Deductible: $387.60 of $500.0078%
Out-of-pocket maximum: $22.42 of $1,500.001%
Copays: office $30.00, specialist $75.00, emergency $350.00
Physical therapy visits: 2 of 20 used

Provider

Billing and rendering

Billing provider: Cornerstone Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7007014674
Network: Out of network
Rendering NPI: 3068738640
Location: San Diego, CA · TIN 68-2977448
Authorisation / referral: PA2026946579 / REF739637

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	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1	$1,182.00	$531.90	—	—	DeniedCO204
Totals						$1,182.00	$531.90	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee
3. M25.561 Pain in right knee

Claim header

Patient account: PA-853045
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-015599 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-02-09: NAVIGATE-HMO (HMO), effective 2024-03-01.
Timely filing	Pass		Received 28 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026946579 on file for 73721.
Provider network	Fail	CO204	Billing provider 7007014674 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Cornerstone Orthopedic Specialists2026-02-09 17:36
Established patient presents with unilateral primary osteoarthritis, right knee; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-03-09 03:15
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-09 09:20
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026946579_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-02-09 to 2026-05-10.
Itemized billitemized_PA-853045.pdf9 pages
Itemised statement totalling $1182.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 7007014674 is out of network and the HMO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-025196	2026-01-18	Summit Reference Lab	$44.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity