Professional claim · CMS-1500 · EDI 837P
CLM-2026-026455
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2025-12-29 at office (POS 11). Received 2026-01-11.
Approved
Billed
$210.00
1 line
Allowed
$130.20
contract rate applied
Plan pays
$100.20
approved
Member owes
$30.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Diego Contreras
- Member ID
- UHC-46032-06
- Date of birth
- 1948-02-23
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-430333
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3409
- Coverage period
- 2023-07-01 to present
- Deductible
- $657.79 of $2,500.0026%
- Out-of-pocket maximum
- $2,487.96 of $10,000.0025%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 7601423271
- Location
- Houston, TX · TIN 58-0916222
- 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 | $210.00 | $130.20 | $30.00 | $100.20 | Paid |
| Totals | $210.00 | $130.20 | $30.00 | $100.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-771286
- 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-000781 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-29: MEDICARE-ADV-A (MA), effective 2023-07-01. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Internal Medicine Associates2025-12-29 10:32
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$210.00
Plan discount
$79.80
contracted rate
Plan paid
$100.20
You may owe
$30.00
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001726 | 2026-02-08 | Sunrise Cardiovascular Associates | $602.00 | Denied |
| CLM-2026-001725 | 2026-02-08 | Sunrise Cardiovascular Associates | $602.00 | Approved |
| CLM-2026-019465 | 2026-01-27 | Lakeside Imaging Center | $936.00 | Approved |
| CLM-2026-004826 | 2025-12-14 | Riverside Medical Group | $260.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.