CLM-2026-026466
Cornerstone Family Practice, Family Medicine. Service 2026-06-18 at office (POS 11). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Carl Bryant
- Member ID
- UHC-04665-45
- Date of birth
- 1945-09-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405973
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9612
- Coverage period
- 2024-11-01 to present
- Deductible
- $61.40 of $3,500.002%
- Out-of-pocket maximum
- $2,717.02 of $14,000.0019%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6150045915
- Network
- Out of network
- Rendering NPI
- 6679444524
- Location
- Minneapolis, MN · TIN 65-3309082
- 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 | $271.00 | $121.95 | — | — | DeniedCO18 |
| Totals | $271.00 | $121.95 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-635750
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-039944 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-18: NULL (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 59 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026465: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Family Practice2026-06-18 15:06
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-08-16 00:28
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-026465: same member, date of service, procedures and billing provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010687 | 2026-08-02 | Canyon Heart Institute | $6,309.00 | Approved |
| CLM-2026-026465 | 2026-06-18 | Cornerstone Family Practice | $271.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.