Professional claim · CMS-1500 · EDI 837P
CLM-2026-000499
Summit Primary Care Associates, Family Medicine. Service 2025-12-03 at office (POS 11). Received 2026-01-15.
Approved
Billed
$540.00
3 lines
Allowed
$334.80
contract rate applied
Plan pays
$294.80
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Arjun Woods
- Member ID
- UHC-68559-43
- Date of birth
- 2005-05-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420339
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6493
- Coverage period
- 2022-03-01 to present
- Deductible
- $1,198.43 of $2,500.0048%
- Out-of-pocket maximum
- $1,951.13 of $7,500.0026%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1481685224
- Network
- In network
- Rendering NPI
- 1816869154
- Location
- Denver, CO · TIN 20-1905659
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $257.00 | $159.34 | $40.00 | $119.34 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $241.00 | $149.42 | $0.00 | $149.42 | Paid |
| Totals | $540.00 | $334.80 | $40.00 | $294.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-695714
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004555 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-03: OPTIONS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 43 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 Summit Primary Care Associates (1481685224). | |
| 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Primary Care Associates2025-12-03 11:55
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$540.00
Plan discount
$205.20
contracted rate
Plan paid
$294.80
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean 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.