CLM-2026-030214
Cornerstone Family Practice, Family Medicine. Service 2026-06-27 at office (POS 11). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Rebecca Carlson
- Member ID
- UHC-32126-56
- Date of birth
- 1983-06-12
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421083
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1827
- Coverage period
- 2023-04-01 to present
- Deductible
- $150.51 of $1,500.0010%
- Out-of-pocket maximum
- $804.41 of $6,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6150045915
- Network
- Out of network
- Rendering NPI
- 7979083657
- 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 | 36415 | Venipuncture | — | 1 | 1 | $25.00 | $11.25 | — | — | DeniedCO204 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $185.00 | $83.25 | — | — | DeniedCO204 |
| 3 | 90471 | Immunization administration | — | 1 | 1,2 | $37.00 | $16.65 | — | — | DeniedCO204 |
| Totals | $247.00 | $111.15 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-564083
- 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-006846 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-27: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 29 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 | Fail | CO204 | Billing provider 6150045915 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Practice2026-06-27 11:34
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-07-26 02:02
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-26 17:50
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 6150045915 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030080 | 2026-04-23 | Meadow Primary Care Associates | $285.00 | Denied |
| CLM-2026-025499 | 2026-03-03 | Harbor Primary Care Associates | $494.00 | 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
No out-of-network benefit on this plan.