CLM-2026-034363
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-10-06 at office (POS 11). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Philip Vasquez
- Member ID
- UHC-19675-29
- Date of birth
- 1942-01-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422646
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9585
- Coverage period
- 2024-02-01 to present
- Deductible
- $705.93 of $1,500.0047%
- Out-of-pocket maximum
- $1,035.73 of $3,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 9280897783
- Location
- Los Angeles, CA · TIN 73-5559083
- Authorisation / referral
- none / REF751823
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 | $321.00 | $199.02 | — | — | Review |
| Totals | $321.00 | $199.02 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-189339
- 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-029010 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-06: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 4 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 Digestive Health Center (4838407417). | |
| 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 encounter for screening for malignant neoplasm of colon;”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Digestive Health Center2026-10-06 10:44
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-10 02:33
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-10 15:48
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with encounter for screening for malignant neoplasm of colon;”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032815 | 2026-05-09 | Lakeside Behavioral Health | $599.00 | Denied |
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
Development letter outstanding.