CLM-2026-027670
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-04-13 to 2026-04-16 at inpatient hospital (POS 21). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Heather Nelson
- Member ID
- UHC-32033-88
- Date of birth
- 1977-12-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429144
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5046
- Coverage period
- 2023-06-01 to present
- Deductible
- $400.16 of $500.0080%
- Out-of-pocket maximum
- $334.69 of $1,000.0033%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6313666565
- Network
- In network
- Rendering NPI
- 7997797122
- Location
- Denver, CO · TIN 59-7558869
- Authorisation / referral
- none / REF996539
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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $232.00 | $127.60 | $108.17 | $19.43 | Paid |
| Totals | $232.00 | $127.60 | $108.17 | $19.43 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-494536
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-13 to 2026-04-17
- 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-020940 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-13: NAVIGATE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 41 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 (6313666565). | |
| 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 Internal Medicine Associates2026-04-16 12:26
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-494536.pdf5 pages
Itemised statement totalling $232.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
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.