Professional claim · CMS-1500 · EDI 837P
CLM-2026-002772
Mesa Family Practice, Family Medicine. Service 2026-01-26 at office (POS 11). Received 2026-02-14.
Approved
Billed
$178.00
1 line
Allowed
$110.36
contract rate applied
Plan pays
$85.36
approved
Member owes
$25.00
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
- Diana Bailey
- Member ID
- UHC-96404-93
- Date of birth
- 1999-10-21
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-417645
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8968
- Coverage period
- 2024-03-01 to present
- Deductible
- $63.90 of $1,500.004%
- Out-of-pocket maximum
- $1,165.08 of $3,000.0039%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9198076652
- Network
- In network
- Rendering NPI
- 3820333821
- Location
- Denver, CO · TIN 38-9829181
- 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 | $178.00 | $110.36 | $25.00 | $85.36 | Paid |
| Totals | $178.00 | $110.36 | $25.00 | $85.36 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-597752
- 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-011801 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-B (MA), effective 2024-03-01. | |
| Timely filing | Pass | Received 19 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 Mesa Family Practice (9198076652). | |
| 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: Mesa Family Practice2026-01-26 18:44
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$178.00
Plan discount
$67.64
contracted rate
Plan paid
$85.36
You may owe
$25.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009481 | 2026-03-03 | Desert Medical Group | $212.00 | Denied |
| CLM-2026-002547 | 2026-04-01 | Unity Digestive Health Center | $1,898.00 | Approved |
| CLM-2026-020902 | 2026-01-30 | Northgate Internal Medicine Associates | $449.00 | 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.