CLM-2026-030901
Cornerstone Family Practice, Family Medicine. Service 2026-03-25 at office (POS 11). Received 2026-04-03.
Member
Resolved through the identity graph
- Member
- Samantha Nunez
- Member ID
- UHC-31120-14
- Date of birth
- 1990-02-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407990
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8102
- Coverage period
- 2022-04-01 to present
- Deductible
- $140.56 of $1,000.0014%
- Out-of-pocket maximum
- $883.13 of $3,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6150045915
- Network
- Out of network
- Rendering NPI
- 2108419302
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $271.00 | $121.95 | — | — | DeniedCO204 |
| Totals | $271.00 | $121.95 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-694205
- 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-008099 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-25: SELECT-EPO (EPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 9 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 Practice2026-03-25 13:41
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-03 06:02
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-03 13:28
Escalated to nurse reviewer for clinical opinion.
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-2026-016137 | 2026-09-19 | Harbor Physical Therapy | $372.00 | Approved |
| CLM-2026-033477 | 2026-03-07 | Riverside Primary Care Associates | $532.00 | Approved |
| CLM-2026-015311 | 2026-02-05 | Cornerstone Regional Medical Center | $2,664.00 | 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.