CLM-2026-017564
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-05-19 at office (POS 11). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Henry Espinoza
- Member ID
- UHC-50850-98
- Date of birth
- 1955-08-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422630
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4234
- Coverage period
- 2023-08-01 to present
- Deductible
- $2,877.61 of $3,500.0082%
- Out-of-pocket maximum
- $1,364.16 of $14,000.0010%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6313666565
- Network
- In network
- Rendering NPI
- 1458237819
- Location
- Denver, CO · TIN 59-7558869
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $90.00 | $55.80 | — | — | DeniedCO29 |
| Totals | $90.00 | $55.80 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-225793
- 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-043674 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-19: NULL (PPO), effective 2023-08-01. | |
| Timely filing | Fail | CO29 | Received 152 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 | Pass | In-network provider Cornerstone Internal Medicine Associates (6313666565). | |
| 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 Internal Medicine Associates2026-05-19 13:02
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-18 01:13
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-18 09:00
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 152 days after the last date of service (limit 90).
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.