Professional claim · CMS-1500 · EDI 837P
CLM-2026-033214
Cornerstone Diabetes Center, Endocrinology. Service 2026-08-27 at office (POS 11). Received 2026-09-07.
Approved
Billed
$346.00
1 line
Allowed
$214.52
contract rate applied
Plan pays
$154.52
approved
Member owes
$60.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Mei Maldonado
- Member ID
- UHC-86595-66
- Date of birth
- 1945-11-02
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425693
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7277
- Coverage period
- 2021-02-01 to present
- Deductible
- $393.77 of $1,000.0039%
- Out-of-pocket maximum
- $861.25 of $4,000.0022%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4170744542
- Network
- In network
- Rendering NPI
- 3822854287
- Location
- Dallas, TX · TIN 78-1267454
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $346.00 | $214.52 | $60.00 | $154.52 | Paid |
| Totals | $346.00 | $214.52 | $60.00 | $154.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
Claim header
- Patient account
- PA-914938
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026852 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-27: NAVIGATE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 11 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 Diabetes Center (4170744542). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Diabetes Center2026-08-27 18:57
Patient seen for thyrotoxicosis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$346.00
Plan discount
$131.48
contracted rate
Plan paid
$154.52
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020211 | 2026-08-15 | Summit Digestive Health Center | $217.00 | Approved |
| CLM-2026-011298 | 2026-05-18 | Sunrise Internal Medicine Associates | $77.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.