CLM-2026-032492
Cornerstone Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-23 at office (POS 11). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Kayla Dixon
- Member ID
- UHC-70561-56
- Date of birth
- 2004-03-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425855
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3651
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,057.69 of $2,500.0042%
- Out-of-pocket maximum
- $1,835.17 of $5,000.0037%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 7007014674
- Network
- Out of network
- Rendering NPI
- 4570986180
- Location
- San Diego, CA · TIN 68-2977448
- Authorisation / referral
- none / REF183385
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $166.00 | $74.70 | — | — | DeniedCO204 |
| 2 | 20610 | Joint injection, major joint | — | 1 | 1 | $269.00 | $121.05 | — | — | DeniedCO204 |
| Totals | $435.00 | $195.75 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M17.12 Unilateral primary osteoarthritis, left knee
- Patient account
- PA-885984
- 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-035927 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-23: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 10 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 7007014674 is out of network and the HMO 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 Orthopedic Specialists2026-09-23 15:53
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-03 01:18
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)2026-10-03 14:53
Member services inquiry logged on this claim; member asked about the status of payment.
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 7007014674 is out of network and the HMO plan has no out-of-network benefit.
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.