Claims workbench/CLM-2026-000041
Professional claim · CMS-1500 · EDI 837P

CLM-2026-000041

Heritage Family Practice, Family Medicine. Service 2026-09-13 at office (POS 11). Received 2026-10-17.

Approved
Billed
$39.00
1 line
Allowed
$24.18
contract rate applied
Plan pays
$0.00
approved
Member owes
$24.18
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Doris Bell
Member ID
UHC-49343-44
Date of birth
1957-03-09
Identity
Verified3 records, confidence 0.96
Claim record
CLMCLM-421130
Relationship
Self, Nashville, TN

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-A MA group GRP-4730
Coverage period
2023-04-01 to present
Deductible
$458.38 of $2,500.0018%
Out-of-pocket maximum
$2,353.45 of $5,000.0047%
Copays
office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits
4 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
9531696935
Network
In network
Rendering NPI
3209856459
Location
Scottsdale, AZ · TIN 58-2905850
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190471Immunization administration—11$39.00$24.18$24.18$0.00Paid
Totals$39.00$24.18$24.18$0.00
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-921646
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

CheckResultCodeDetail
Member identityPassAttached to MBR-034007 (verified, link confidence 0.96).
EligibilityPassActive on 2026-09-13: MEDICARE-ADV-A (MA), effective 2023-04-01.
Timely filingPassReceived 34 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Family Practice (9531696935).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Heritage Family Practice2026-09-13 17:01

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$39.00
Plan discount
$14.82
contracted rate
Plan paid
$0.00
You may owe
$24.18
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity