Professional claim · CMS-1500 · EDI 837P
CLM-2026-000057
Valley Family Practice, Family Medicine. Service 2026-09-20 at office (POS 11). Received 2026-10-06.
Denied
Billed
$364.00
2 lines
Allowed
$225.68
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Dan Carroll
- Member ID
- UHC-28665-19
- Date of birth
- 2008-09-22
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-404466
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2081
- Coverage period
- 2021-05-01 to 2026-05-25
- Deductible
- $2,535.33 of $3,500.0072%
- Out-of-pocket maximum
- $4,611.32 of $10,500.0044%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 8782623424
- Location
- Houston, TX · TIN 34-3279519
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $152.00 | $94.24 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $212.00 | $131.44 | — | — | DeniedCO27 |
| Totals | $364.00 | $225.68 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-419452
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031143 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-20 is after coverage terminated on 2026-05-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 16 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 Valley Family Practice (3411841638). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Family Practice2026-09-20 10:12
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-10-06 05:58
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-09-20 is after coverage terminated on 2026-05-25.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.