CLM-2026-024024
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2025-12-25 to 2025-12-26 at inpatient hospital (POS 21). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Teresa Howell
- Member ID
- UHC-92058-49
- Date of birth
- 1959-10-07
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-432669
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6736
- Coverage period
- 2022-09-01 to present
- Deductible
- $26.32 of $500.005%
- Out-of-pocket maximum
- $216.75 of $1,500.0014%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 3561668849
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2025371624 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $32,041.00 | $17,622.55 | — | — | Review |
| Totals | $32,041.00 | $17,622.55 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-980924
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2025-12-25 to 2025-12-26
- 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-001682 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: MEDICARE-ADV-A (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025371624 on file for 27447. | |
| 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 | Review | HIGH | Billed $32,041.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Bone and Joint Center2025-12-26 18:51
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-01-06 03:51
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
Attachments
Documents received with the claim
- Prior auth letterPA2025371624_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2025-12-25 to 2026-03-25.
- Itemized billitemized_PA-980924.pdf7 pages
Itemised statement totalling $32041.00 across 1 line.
- Medical recordrecords_PA-980924.pdf7 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43High-dollar review: Billed $32,041.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
- AI recommendationApproved2026-10-21 14:15The claim for a total knee arthroplasty is supported by the diagnosis of unilateral primary osteoarthritis, left knee. The provider is in-network, and the service was authorized. The clinical note and discharge summary confirm the procedure was completed without complication. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off, but all other checks have passed. The member is eligible, and the claim is not a duplicate. The high-dollar review flagged the claim due to the billed amount, but this is expected and requires human sign-off.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 20e8a9b8
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000631 | 2026-02-14 | Desert Internal Medicine Associates | $64.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for a total knee arthroplasty is supported by the diagnosis of unilateral primary osteoarthritis, left knee. The provider is in-network, and the service was authorized. The clinical note and discharge summary confirm the procedure was completed without complication. The billed amount exceeds the auto-adjudication ceiling, requiring examiner sign-off, but all other checks have passed. The member is eligible, and the claim is not a duplicate. The high-dollar review flagged the claim due to the billed amount, but this is expected and requires human sign-off.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Above auto-pay ceiling; payable once an examiner signs off.