CLM-2026-024125
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-05-31 at outpatient hospital (POS 22). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Gabriel Fisher
- Member ID
- UHC-15892-86
- Date of birth
- 1962-02-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403887
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2493
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,505.62 of $2,500.0060%
- Out-of-pocket maximum
- $2,384.18 of $7,500.0032%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 1386265551
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2025502239 / 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 | $1,598.00 | $719.10 | $719.10 | $0.00 | Paid |
| Totals | $1,598.00 | $719.10 | $719.10 | $0.00 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-965914
- 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-025454 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-31: OPTIONS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025502239 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 Specialists2026-05-31 17:55
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025502239_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-05-31 to 2026-08-29.
- Itemized billitemized_PA-965914.pdf4 pages
Itemised statement totalling $1598.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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-2026-019995 | 2026-04-03 | Evergreen Orthopedic Specialists | $291.00 | 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.