Claims workbench/CLM-2026-032389

Institutional claim · UB-04 · EDI 837I

CLM-2026-032389

Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-07 at outpatient hospital (POS 22). Received 2026-03-20.

Needs reviewOut of network

Billed

$1,580.00

1 line

Allowed

$711.00

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Sophia Martinez
Member ID: UHC-22861-85
Date of birth: 1950-04-27
Identity: Verified4 records, confidence 1.00
Claim record: CLMCLM-417692
Relationship: Self, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-4219
Coverage period: 2025-09-01 to present
Deductible: $542.00 of $2,500.0022%
Out-of-pocket maximum: $992.03 of $5,000.0020%
Copays: office $20.00, specialist $50.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Cornerstone Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7007014674
Network: Out of network
Rendering NPI: 1325435612
Location: San Diego, CA · TIN 68-2977448
Authorisation / referral: PA2026978548 / 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	73721 rev 0610	MRI lower extremity joint without contrast	—	1	1	$1,580.00	$711.00	—	—	Review
Totals						$1,580.00	$711.00	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-317497
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-021022 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-03-07: MEDICARE-ADV-B (MA), effective 2025-09-01.
Timely filing	Pass		Received 13 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026978548 on file for 73721.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Established patient presents with unilateral primary osteoarthritis, left knee; symptoms r”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Cornerstone Orthopedic Specialists2026-03-07 10:37
Established patient presents with unilateral primary osteoarthritis, left knee; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
SystemSystem: Claims system2026-03-20 01:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-20 17:09
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026978548_approval.pdf2 pages
Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-03-07 to 2026-06-05.
Itemized billitemized_PA-317497.pdf2 pages
Itemised statement totalling $1580.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Established patient presents with unilateral primary osteoarthritis, left knee; symptoms r”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014292	2026-06-24	Riverside Bone and Joint Center	$248.00	Approved
CLM-2026-033433	2026-03-23	Heritage Primary Care Associates	$404.00	Needs review

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity