Claims workbench/CLM-2026-000053
Professional claim · CMS-1500 · EDI 837P

CLM-2026-000053

Meadow Medical Group, Internal Medicine. Service 2026-03-16 at office (POS 11). Received 2026-04-17.

Approved
Billed
$398.00
1 line
Allowed
$246.76
contract rate applied
Plan pays
$216.76
approved
Member owes
$30.00
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
Bruce Holmes
Member ID
UHC-07074-32
Date of birth
1987-02-03
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-417903
Relationship
Child, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-1662
Coverage period
2024-06-01 to present
Deductible
$811.32 of $1,500.0054%
Out-of-pocket maximum
$1,880.22 of $4,500.0042%
Copays
office $30.00, specialist $75.00, emergency $150.00
Physical therapy visits
0 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
3950077545
Network
In network
Rendering NPI
7286605564
Location
Denver, CO · TIN 15-9022901
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199215Office visit, established patient, high complexity—11$398.00$246.76$30.00$216.76Paid
Totals$398.00$246.76$30.00$216.76
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. J44.9 COPD, unspecified
  • 3. I48.91 Unspecified atrial fibrillation
Claim header
Patient account
PA-555696
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-026313 (verified, link confidence 0.99).
EligibilityPassActive on 2026-03-16: SELECT-EPO (EPO), effective 2024-06-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Medical Group (3950077545).
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: Meadow Medical Group2026-03-16 10:44

    Established patient presents with chronic kidney disease, stage 3 unspecified; 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
$398.00
Plan discount
$151.24
contracted rate
Plan paid
$216.76
You may owe
$30.00
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