CLM-2026-033431
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-03-27 at office (POS 11). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Donald Fowler
- Member ID
- UHC-43583-77
- Date of birth
- 2007-08-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421742
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8089
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,178.63 of $3,500.0034%
- Out-of-pocket maximum
- $1,479.86 of $7,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 7518384624
- Location
- Houston, TX · TIN 58-0916222
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $310.00 | $192.20 | $30.00 | $162.20 | Paid |
| Totals | $310.00 | $192.20 | $30.00 | $162.20 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-272953
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010634 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Pass | Received 3 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 (1575429455). | |
| 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 Associates2026-03-27 14:18
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031581 | 2026-06-05 | Desert Diabetes Center | $291.00 | Approved |
| CLM-2026-029702 | 2026-04-13 | Heritage Primary Care Associates | $25.00 | Denied |
| CLM-2026-029701 | 2026-04-13 | Heritage Primary Care Associates | $25.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.