Professional claim · CMS-1500 · EDI 837P
CLM-2026-000317
Desert Primary Care Associates, Family Medicine. Service 2026-04-20 at office (POS 11). Received 2026-04-29.
Approved
Billed
$244.00
2 lines
Allowed
$151.28
contract rate applied
Plan pays
$128.34
approved
Member owes
$22.94
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
- Scott Robertson
- Member ID
- UHC-77048-48
- Date of birth
- 2002-06-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-426562
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6449
- Coverage period
- 2025-10-01 to present
- Deductible
- $227.94 of $2,500.009%
- Out-of-pocket maximum
- $1,594.13 of $7,500.0021%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6762345471
- Network
- In network
- Rendering NPI
- 3067406652
- Location
- Dallas, TX · TIN 75-4232082
- 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 | 90471 | Immunization administration | — | 1 | 1 | $37.00 | $22.94 | $22.94 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $207.00 | $128.34 | $0.00 | $128.34 | Paid |
| Totals | $244.00 | $151.28 | $22.94 | $128.34 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-181708
- 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-009205 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-20: CORE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 9 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 Desert Primary Care Associates (6762345471). | |
| 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: Desert Primary Care Associates2026-04-20 14:12
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$244.00
Plan discount
$92.72
contracted rate
Plan paid
$128.34
You may owe
$22.94
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004943 | 2026-09-19 | Heritage Physical Therapy | $323.00 | Approved |
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.