CLM-2026-025715
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-27 at outpatient hospital (POS 22). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Carl Rihards
- Member ID
- UHC-93428-71
- Date of birth
- 1941-08-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405003
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8509
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,754.61 of $2,500.0070%
- Out-of-pocket maximum
- $2,152.85 of $5,000.0043%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 3092458983
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026672671 / 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 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $7,109.00 | $3,199.05 | $1,236.12 | $1,962.93 | Paid |
| Totals | $7,109.00 | $3,199.05 | $1,236.12 | $1,962.93 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- 2. M17.11 Unilateral primary osteoarthritis, right knee
- Patient account
- PA-539760
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005038 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-27: OPTIONS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026672671 on file for 29881. | |
| 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 Specialists2026-07-27 16:17
Follow-up for other tear of medial meniscus, right knee, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026672671_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-07-27 to 2026-10-25.
- Itemized billitemized_PA-539760.pdf6 pages
Itemised statement totalling $7109.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.