CLM-2026-026984
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-02-04 to 2026-02-07 at inpatient hospital (POS 21). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Alexander Mason
- Member ID
- UHC-72900-81
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425685
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4791
- Coverage period
- 2023-01-01 to present
- Deductible
- $711.22 of $3,500.0020%
- Out-of-pocket maximum
- $3,937.99 of $14,000.0028%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 5917066503
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026115944 / 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 | 27447 rev 0360 | Total knee arthroplasty | — | 1 | 1 | $40,701.00 | $18,315.45 | — | — | PendedIDQ |
| Totals | $40,701.00 | $18,315.45 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-169441
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 470
- Admit / discharge
- 2026-02-04 to 2026-02-06
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003229; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-02-04: - (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026115944 on file for 27447. | |
| 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 | Review | HIGH | Billed $40,701.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required. Billed amount above auto-pay ceiling |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Orthopedic Specialists2026-02-07 11:45
Patient seen for low back pain, unspecified. Procedure completed without complication; length of stay within expected range for the DRG. Discharge summary attached.
- SystemSystem: Claims system2026-03-04 02:38
Billed amount exceeds the auto-adjudication ceiling. Requires examiner sign-off under the high-dollar policy.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-04 17:32
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026115944_approval.pdf2 pages
Utilisation management approval letter for 27447 (Total knee arthroplasty), valid 2026-02-04 to 2026-05-05.
- Itemized billitemized_PA-169441.pdf8 pages
Itemised statement totalling $40701.00 across 1 line.
- Medical recordrecords_PA-169441.pdf7 pages
Discharge summary and operative report.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003229; payment withheld until the identity is confirmed. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. High-dollar review: Billed $40,701.00 exceeds the auto-adjudication ceiling of $15,000.00; examiner sign-off required.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Above auto-pay ceiling; payable once an examiner signs off.