CLM-2026-033966
Cornerstone Internal Medicine Associates, Internal Medicine. Service 2026-02-08 at office (POS 11). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Pamela Lawson
- Member ID
- UHC-19051-72
- Date of birth
- 1959-12-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417697
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8853
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,401.49 of $3,500.0040%
- Out-of-pocket maximum
- $886.35 of $14,000.006%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1575429455
- Network
- In network
- Rendering NPI
- 1474963372
- 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 | $230.00 | $142.60 | — | — | PendedIDQ |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $298.00 | $184.76 | — | — | PendedIDQ |
| Totals | $528.00 | $327.36 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-881490
- 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 | Fail | IDQ | Member record is in open steward case CASE-002912; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-02-08: NULL (PPO), effective 2023-01-01. | |
| 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 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 Associates2026-02-08 09:43
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002912; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.