CLM-2026-025247
Cornerstone Diabetes Center, Endocrinology. Service 2026-02-04 at office (POS 11). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Valentina Aguilar
- Member ID
- UHC-88614-93
- Date of birth
- 1943-05-19
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-416537
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0790
- Coverage period
- 2025-09-01 to present
- Deductible
- $318.39 of $2,500.0013%
- Out-of-pocket maximum
- $1,649.72 of $5,000.0033%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4170744542
- Network
- In network
- Rendering NPI
- 5487230927
- Location
- Dallas, TX · TIN 78-1267454
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $276.00 | $171.12 | $60.00 | $111.12 | Paid |
| Totals | $276.00 | $171.12 | $60.00 | $111.12 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-233565
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018756 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-04: CHOICE-PLUS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 34 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 Diabetes Center (4170744542). | |
| 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 Diabetes Center2026-02-04 15:01
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031427 | 2026-08-20 | Desert Heart Institute | $8,065.00 | 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.