Professional claim · CMS-1500 · EDI 837P
CLM-2026-002195
Sunrise Diabetes Center, Endocrinology. Service 2026-08-20 at office (POS 11). Received 2026-09-09.
Approved
Billed
$302.00
2 lines
Allowed
$187.24
contract rate applied
Plan pays
$148.80
approved
Member owes
$38.44
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Betty Pena
- Member ID
- UHC-15755-28
- Date of birth
- 1953-10-03
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-414269
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5716
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,889.93 of $2,500.0076%
- Out-of-pocket maximum
- $2,629.36 of $7,500.0035%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 1154539146
- Network
- In network
- Rendering NPI
- 1499528762
- Location
- Tampa, FL · TIN 90-8967175
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $62.00 | $38.44 | $38.44 | $0.00 | Paid |
| 2 | 95251 | Continuous glucose monitoring, analysis | 25 | 1 | 2 | $240.00 | $148.80 | $0.00 | $148.80 | Paid |
| Totals | $302.00 | $187.24 | $38.44 | $148.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
Claim header
- Patient account
- PA-294360
- 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-000580 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: NULL (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 20 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 Sunrise Diabetes Center (1154539146). | |
| 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: Sunrise Diabetes Center2026-08-20 11:38
Patient seen for thyrotoxicosis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$302.00
Plan discount
$114.76
contracted rate
Plan paid
$148.80
You may owe
$38.44
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026444 | 2025-12-18 | Canyon Primary Care Associates | $268.00 | 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.