Professional claim · CMS-1500 · EDI 837P
CLM-2026-001536
Pinecrest Medical Group, Internal Medicine. Service 2026-08-16 at office (POS 11). Received 2026-09-18.
Approved
Billed
$336.00
2 lines
Allowed
$208.32
contract rate applied
Plan pays
$188.32
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
- Julie Evans
- Member ID
- UHC-51135-08
- Date of birth
- 1978-10-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431850
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7869
- Coverage period
- 2024-08-01 to present
- Deductible
- $285.91 of $500.0057%
- Out-of-pocket maximum
- $625.17 of $2,000.0031%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 3066149535
- Location
- Minneapolis, MN · TIN 79-7771425
- 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 | $42.00 | $26.04 | $20.00 | $6.04 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $294.00 | $182.28 | $0.00 | $182.28 | Paid |
| Totals | $336.00 | $208.32 | $20.00 | $188.32 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
Claim header
- Patient account
- PA-731948
- 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-029094 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-16: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 33 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 Pinecrest Medical Group (8331715671). | |
| 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: Pinecrest Medical Group2026-08-16 18:55
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$336.00
Plan discount
$127.68
contracted rate
Plan paid
$188.32
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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011631 | 2026-03-30 | Canyon Primary Care Associates | $487.00 | 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.