Claims workbench/CLM-2026-025650

Institutional claim · UB-04 · EDI 837I

CLM-2026-025650

Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-10-02 to 2026-10-04 at inpatient hospital (POS 21). Received 2026-10-15.

DeniedOut of network

Billed

$35,527.00

1 line

Allowed

$15,987.15

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Rachel Lopez
Member ID: UHC-43524-49
Date of birth: 1967-11-16
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-422495
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-0585
Coverage period: 2022-01-01 to present
Deductible: $305.83 of $3,500.009%
Out-of-pocket maximum: $1,440.32 of $7,000.0021%
Copays: office $20.00, specialist $60.00, emergency $350.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Cornerstone Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7007014674
Network: Out of network
Rendering NPI: 3720756915
Location: San Diego, CA · TIN 68-2977448
Authorisation / referral: PA2025394368 / REF743928

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	$35,527.00	$15,987.15	—	—	DeniedCO204
Totals						$35,527.00	$15,987.15	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. M17.11 Unilateral primary osteoarthritis, right knee

Claim header

Patient account: PA-404831
Frequency code: 1 (original)
Accident: No
DRG: 470
Admit / discharge: 2026-10-02 to 2026-10-04
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-005146 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-10-02: NAVIGATE-HMO (HMO), effective 2022-01-01.
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 PA2025394368 on file for 27447.
Provider network	Fail	CO204	Billing provider 7007014674 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
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 $35,527.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Cornerstone Orthopedic Specialists2026-10-04 16:32
Follow-up for pain in right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-10-15 05:32
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-15 15:43
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025394368_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-10-02 to 2026-12-31.
Itemized billitemized_PA-404831.pdf5 pages
Itemised statement totalling $35527.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 7007014674 is out of network and the HMO plan has no out-of-network benefit. High-dollar review: Billed $35,527.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-027380	2026-01-29	Heritage Community Hospital	$3,083.00	Approved
CLM-2026-021336	2025-12-31	Lakeside Reference Lab	$67.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity