CLM-2026-016556
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Heather Diaz
- Member ID
- UHC-41818-71
- Date of birth
- 1945-03-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410541
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2772
- Coverage period
- 2025-01-01 to 2026-04-25
- Deductible
- $319.67 of $500.0064%
- Out-of-pocket maximum
- $424.91 of $1,500.0028%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 7522508846
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026079687 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,235.00 | $555.75 | $217.87 | $337.88 | Paid |
| Totals | $1,235.00 | $555.75 | $217.87 | $337.88 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-840021
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001128 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-02: NULL (PPO), effective 2025-01-01, terms 2026-04-25. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026079687 on file for 73721. | |
| 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 Specialists2026-01-02 15:27
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026079687_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-01-02 to 2026-04-02.
- Itemized billitemized_PA-840021.pdf7 pages
Itemised statement totalling $1235.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000896 | 2025-12-08 | Evergreen Orthopedic Specialists | $6,918.00 | Needs review |
| CLM-2026-000895 | 2025-12-08 | Pinecrest Bone and Joint Center | $6,918.00 | 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.