CLM-2026-025461
Cornerstone Bone and Joint Center, Orthopedic Surgery. Service 2026-09-01 at outpatient hospital (POS 22). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Amanda Yang
- Member ID
- UHC-99907-18
- Date of birth
- 1941-10-25
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-432377
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3986
- Coverage period
- 2021-02-01 to present
- Deductible
- $2,092.14 of $3,500.0060%
- Out-of-pocket maximum
- $2,194.11 of $7,000.0031%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7661667833
- Network
- In network
- Rendering NPI
- 7328765830
- Location
- Tempe, AZ · TIN 28-0381608
- Authorisation / referral
- PA2025168404 / 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 | $1,439.00 | $791.45 | $791.45 | $0.00 | Paid |
| 2 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $6,117.00 | $3,364.35 | $1,440.79 | $1,923.56 | Paid |
| Totals | $7,556.00 | $4,155.80 | $2,232.24 | $1,923.56 | ||||||
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- Patient account
- PA-821481
- 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-029005 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-01: MEDICARE-ADV-B (MA), effective 2021-02-01. | |
| 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 PA2025168404 on file for 73721, 29881. | |
| 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 | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Bone and Joint Center2026-09-01 11:04
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025168404_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-01 to 2026-11-30.
- Itemized billitemized_PA-821481.pdf9 pages
Itemised statement totalling $7556.00 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
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.