Professional claim · CMS-1500 · EDI 837P
CLM-2026-001046
Harbor Medical Group, Family Medicine. Service 2026-07-12 at office (POS 11). Received 2026-07-15.
Approved
Billed
$687.00
3 lines
Allowed
$425.94
contract rate applied
Plan pays
$385.94
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Pamela Ortega
- Member ID
- UHC-81594-20
- Date of birth
- 1956-08-27
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-411960
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4826
- Coverage period
- 2024-07-01 to present
- Deductible
- $779.23 of $1,000.0078%
- Out-of-pocket maximum
- $719.96 of $2,000.0036%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1145537761
- Network
- In network
- Rendering NPI
- 5627606283
- Location
- Phoenix, AZ · TIN 88-8462048
- 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 | $145.00 | $89.90 | $40.00 | $49.90 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $260.00 | $161.20 | $0.00 | $161.20 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $282.00 | $174.84 | $0.00 | $174.84 | Paid |
| Totals | $687.00 | $425.94 | $40.00 | $385.94 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-884542
- 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-027731 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-12: N/A (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 3 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 Harbor Medical Group (1145537761). | |
| 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: Harbor Medical Group2026-07-12 17:16
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$687.00
Plan discount
$261.06
contracted rate
Plan paid
$385.94
You may owe
$40.00
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.