CLM-2026-019436
Cornerstone Imaging Center, Radiology. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Mark Jimenez
- Member ID
- UHC-85724-40
- Date of birth
- 1974-06-08
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-425102
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8990
- Coverage period
- 2023-09-01 to present
- Deductible
- $280.10 of $2,500.0011%
- Out-of-pocket maximum
- $2,661.31 of $7,500.0035%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9835477198
- Network
- In network
- Rendering NPI
- 9835477198
- Location
- Tampa, FL · TIN 89-9420622
- Authorisation / referral
- PA2025876618 / REF932338
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,238.00 | $680.90 | $680.90 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $122.00 | $67.10 | $67.10 | $0.00 | Paid |
| Totals | $1,360.00 | $748.00 | $748.00 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-194386
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013341 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-07: CORE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025876618 on file for 74177. | |
| Provider network | Pass | In-network provider Cornerstone Imaging Center (9835477198). | |
| 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 Imaging Center2026-04-07 11:12
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025876618_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-07 to 2026-07-06.
- Itemized billitemized_PA-194386.pdf9 pages
Itemised statement totalling $1360.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032939 | 2026-02-25 | Harbor Clinical Laboratories | $127.00 | Denied |
| CLM-2026-027888 | 2026-05-10 | Desert Imaging Center | $877.00 | Approved |
| CLM-2026-008537 | 2026-01-06 | Mesa Internal Medicine Associates | $3,106.00 | Needs review |
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.