Professional claim · CMS-1500 · EDI 837P
CLM-2026-000249
Heritage Family Practice, Family Medicine. Service 2026-09-10 at office (POS 11). Received 2026-10-11.
Approved
Billed
$402.00
3 lines
Allowed
$249.24
contract rate applied
Plan pays
$235.60
approved
Member owes
$13.64
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
- William Garcia
- Member ID
- UHC-02353-22
- Date of birth
- 1954-01-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-419755
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3672
- Coverage period
- 2022-07-01 to present
- Deductible
- $913.00 of $3,500.0026%
- Out-of-pocket maximum
- $2,183.92 of $10,500.0021%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 2439165657
- Location
- Scottsdale, AZ · TIN 98-1410500
- 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 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $13.64 | $13.64 | $0.00 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $336.00 | $208.32 | $0.00 | $208.32 | Paid |
| 3 | 90471 | Immunization administration | — | 1 | 1,2 | $44.00 | $27.28 | $0.00 | $27.28 | Paid |
| Totals | $402.00 | $249.24 | $13.64 | $235.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-454325
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035397 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-10: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 31 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 Heritage Family Practice (3586851693). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Family Practice2026-09-10 09:35
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$402.00
Plan discount
$152.76
contracted rate
Plan paid
$235.60
You may owe
$13.64
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.