Claims workbench/CLM-2026-030763
Professional claim · CMS-1500 · EDI 837P

CLM-2026-030763

Cornerstone Diabetes Center, Endocrinology. Service 2026-01-16 at office (POS 11). Received 2026-01-20.

Approved
Billed
$362.00
2 lines
Allowed
$224.44
contract rate applied
Plan pays
$149.44
approved
Member owes
$75.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Steven Ellis
Member ID
UHC-97673-76
Date of birth
1944-12-28
Identity
Verified4 records, confidence 0.99
Claim record
CLMCLM-407481
Relationship
Spouse, Jacksonville, FL

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-2183
Coverage period
2023-12-01 to present
Deductible
$183.99 of $500.0037%
Out-of-pocket maximum
$657.42 of $1,500.0044%
Copays
office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits
16 of 20 used

Provider

Billing and rendering

Billing provider
Cornerstone Diabetes Center
Endocrinology · taxonomy 207RE0101X
NPI
4170744542
Network
In network
Rendering NPI
8150387685
Location
Dallas, TX · TIN 78-1267454
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$312.00$193.44$75.00$118.44Paid
283036Hemoglobin A1c—12$50.00$31.00$0.00$31.00Paid
Totals$362.00$224.44$75.00$149.44
Diagnoses (ICD-10-CM)
  • 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
  • 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
Patient account
PA-720361
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-006078 (verified, link confidence 0.99).
EligibilityPassActive on 2026-01-16: OPTIONS-PPO (PPO), effective 2023-12-01.
Timely filingPassReceived 4 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Cornerstone Diabetes Center (4170744542).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Cornerstone Diabetes Center2026-01-16 17:08

    Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$362.00
Plan discount
$137.56
contracted rate
Plan paid
$149.44
You may owe
$75.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity