Professional claim · CMS-1500 · EDI 837P
CLM-2026-001329
Unity Internal Medicine Associates, Internal Medicine. Service 2025-12-12 at office (POS 11). Received 2026-01-18.
ApprovedOut of network
Billed
$481.00
3 lines
Allowed
$216.45
contract rate applied
Plan pays
$196.45
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Kelly Gordon
- Member ID
- UHC-60170-41
- Date of birth
- 1941-07-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406585
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0774
- Coverage period
- 2025-02-01 to present
- Deductible
- $323.78 of $1,000.0032%
- Out-of-pocket maximum
- $434.09 of $2,000.0022%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 1646465355
- Location
- Atlanta, GA · TIN 10-7193981
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $60.00 | $27.00 | $20.00 | $7.00 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1,2 | $118.00 | $53.10 | $0.00 | $53.10 | Paid |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $303.00 | $136.35 | $0.00 | $136.35 | Paid |
| Totals | $481.00 | $216.45 | $20.00 | $196.45 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-347486
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005425 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-12: NULL (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 37 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Internal Medicine Associates2025-12-12 10:45
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$481.00
Plan discount
$264.55
out-of-network allowance
Plan paid
$196.45
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007954 | 2026-05-08 | Mesa Clinical Laboratories | $56.00 | Approved |
| CLM-2026-012952 | 2026-03-23 | Northgate Clinical Laboratories | $36.00 | Approved |
| CLM-2026-014385 | 2026-03-30 | Unity Community Hospital | $2,602.00 | 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.