CLM-2026-017454
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2026-06-19 at outpatient hospital (POS 22). Received 2026-08-01.
Member
Resolved through the identity graph
- Member
- Ruth Gray
- Member ID
- UHC-95105-58
- Date of birth
- 1977-05-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416365
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2021-10-01 to present
- Deductible
- $649.96 of $2,500.0026%
- Out-of-pocket maximum
- $1,382.34 of $7,500.0018%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 3737309864
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2025364048 / 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 | $1,444.00 | $794.20 | $794.20 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 2 | $6,549.00 | $3,601.95 | $1,310.45 | $2,291.50 | Paid |
| Totals | $7,993.00 | $4,396.15 | $2,104.65 | $2,291.50 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-698540
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021250 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-19: OPTIONS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025364048 on file for 73721, 29881. | |
| Provider network | Pass | In-network provider Cornerstone Bone and Joint Center (7661667833). | |
| 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 Bone and Joint Center2026-06-19 15:02
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025364048_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-06-19 to 2026-09-17.
- Itemized billitemized_PA-698540.pdf4 pages
Itemised statement totalling $7993.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017455 | 2026-06-19 | Sunrise Orthopedic Specialists | $7,993.00 | Needs review |
| CLM-2026-004963 | 2026-02-26 | Riverside Digestive Health Center | $249.00 | 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.