CLM-2026-031381
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-02-19 to 2026-02-20 at inpatient hospital (POS 21). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Lucia Fuller
- Member ID
- UHC-16929-82
- Date of birth
- 1976-05-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416315
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9283
- Coverage period
- 2024-08-01 to 2026-01-25
- Deductible
- $739.32 of $1,500.0049%
- Out-of-pocket maximum
- $1,138.72 of $3,000.0038%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5055109818
- Network
- In network
- Rendering NPI
- 6358443292
- Location
- Denver, CO · TIN 34-0670860
- Authorisation / referral
- none / none
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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $256.00 | $140.80 | — | — | DeniedCO27 |
| Totals | $256.00 | $140.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-536370
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-19 to 2026-02-23
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005729 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-19 is after coverage terminated on 2026-01-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 Associates2026-02-20 11:25
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-24 05:45
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-24 08:47
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-536370.pdf2 pages
Itemised statement totalling $256.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-19 is after coverage terminated on 2026-01-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024367 | 2026-01-01 | Lakeside Internal Medicine Associates | $230.00 | 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
Service after coverage termination.