CLM-2026-024558
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-10-03 at office (POS 11). Received 2026-10-16.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7240
- Coverage period
- 2024-11-01 to present
- Deductible
- $101.74 of $500.0020%
- Out-of-pocket maximum
- $363.73 of $1,000.0036%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 3365740802
- Location
- Houston, TX · TIN 58-0916222
- Authorisation / referral
- none / REF178980
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $291.00 | $180.42 | — | — | PendedCO16 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $348.00 | $215.76 | — | — | PendedCO16 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $73.00 | $45.26 | — | — | PendedCO16 |
| Totals | $712.00 | $441.44 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-975864
- 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 | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-10-03: NAVIGATE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| 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 (1575429455). | |
| 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 Associates2026-10-03 11:03
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Clean claim, priced at contract rate.