CLM-2026-030902
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-08-24 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Karen Warren
- Member ID
- UHC-82850-96
- Date of birth
- 1955-07-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425725
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7904
- Coverage period
- 2021-06-01 to present
- Deductible
- $1,270.30 of $3,500.0036%
- Out-of-pocket maximum
- $3,801.00 of $10,500.0036%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- Authorisation / referral
- PA2026765368 / REF495182
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,169.00 | $976.05 | — | — | DeniedCO204 |
| Totals | $2,169.00 | $976.05 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-292899
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009266 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-24: CORE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026765368 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 5966486339 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Reference Lab2026-08-24 13:25
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-09-15 01:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026765368_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-24 to 2026-11-22.
- Itemized billitemized_PA-292899.pdf2 pages
Itemised statement totalling $2169.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5966486339 is out of network and the HMO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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.