CLM-2026-028609
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-06 at outpatient hospital (POS 22). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Brittany Campbell
- Member ID
- UHC-99813-04
- Date of birth
- 1953-04-18
- Identity
- Verified5 records, confidence 0.88
- Claim record
- CLMCLM-405205
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1271
- Coverage period
- 2024-04-01 to present
- Deductible
- $1,512.71 of $2,500.0061%
- Out-of-pocket maximum
- $2,869.75 of $10,000.0029%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 3538877382
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- PA2026760166 / 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 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,765.00 | $794.25 | $794.25 | $0.00 | Paid |
| Totals | $1,765.00 | $794.25 | $794.25 | $0.00 | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
- Patient account
- PA-384564
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015276 (verified, link confidence 0.88). | |
| Eligibility | Pass | Active on 2026-09-06: CHOICE-PLUS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026760166 on file for 73721. | |
| 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 Specialists2026-09-06 11:17
Patient seen for unilateral primary osteoarthritis, left knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026760166_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-09-06 to 2026-12-05.
- Itemized billitemized_PA-384564.pdf2 pages
Itemised statement totalling $1765.00 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 13:43Provider 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-2026-021627 | 2026-02-14 | Unity Medical Group | $99.00 | Approved |
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.