Professional claim · CMS-1500 · EDI 837P
CLM-2026-001290
Desert Cardiovascular Associates, Cardiology. Service 2026-07-10 at office (POS 11). Received 2026-07-12.
Approved
Billed
$416.00
1 line
Allowed
$257.92
contract rate applied
Plan pays
$197.92
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Julia George
- Member ID
- UHC-91645-03
- Date of birth
- 1959-01-27
- Identity
- Verified2 records, confidence 0.94
- Claim record
- CLMCLM-407266
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-6506
- Coverage period
- 2022-03-01 to present
- Deductible
- $2,110.13 of $3,500.0060%
- Out-of-pocket maximum
- $1,631.19 of $7,000.0023%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 9897032733
- Location
- Houston, TX · TIN 63-6537518
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $416.00 | $257.92 | $60.00 | $197.92 | Paid |
| Totals | $416.00 | $257.92 | $60.00 | $197.92 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I48.91 Unspecified atrial fibrillation
Claim header
- Patient account
- PA-729856
- 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-038141 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-07-10: UNKNOWN (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 2 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 Cardiovascular Associates (1421288352). | |
| 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: Desert Cardiovascular Associates2026-07-10 18:50
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$416.00
Plan discount
$158.08
contracted rate
Plan paid
$197.92
You may owe
$60.00
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.