CLM-2026-030555
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-08-31 at office (POS 11). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Dennis Ward
- Member ID
- UHC-92140-80
- Date of birth
- 1966-04-11
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-423053
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8851
- Coverage period
- 2022-10-01 to present
- Deductible
- $639.84 of $1,000.0064%
- Out-of-pocket maximum
- $567.03 of $3,000.0019%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5055109818
- Network
- In network
- Rendering NPI
- 5209174502
- Location
- Denver, CO · TIN 34-0670860
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $299.00 | $185.38 | $40.00 | $145.38 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 2 | $68.00 | $42.16 | $0.00 | $42.16 | Paid |
| Totals | $367.00 | $227.54 | $40.00 | $187.54 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-646963
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016545 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-31: MEDICARE-ADV-B (MA), effective 2022-10-01. | |
| Timely filing | Pass | Received 14 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 (5055109818). | |
| 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 Associates2026-08-31 13:52
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean 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.