Professional claim · CMS-1500 · Provider portal
CLM-2026-002800
Heritage Family Practice, Family Medicine. Service 2026-02-24 at office (POS 11). Received 2026-03-25.
Approved
Billed
$414.00
2 lines
Allowed
$256.68
contract rate applied
Plan pays
$226.68
approved
Member owes
$30.00
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
- Andrew Griffin
- Member ID
- UHC-72617-99
- Date of birth
- 1956-09-07
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-416508
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-9689
- Coverage period
- 2022-04-01 to present
- Deductible
- $2,109.41 of $2,500.0084%
- Out-of-pocket maximum
- $1,443.38 of $5,000.0029%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 9351048738
- Location
- Scottsdale, AZ · TIN 98-1410500
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $258.00 | $159.96 | $30.00 | $129.96 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $156.00 | $96.72 | $0.00 | $96.72 | Paid |
| Totals | $414.00 | $256.68 | $30.00 | $226.68 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-255915
- 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-021885 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-24: N/A (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 29 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 Heritage Family Practice (3586851693). | |
| 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: Heritage Family Practice2026-02-24 18:46
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$414.00
Plan discount
$157.32
contracted rate
Plan paid
$226.68
You may owe
$30.00
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-2026-019570 | 2026-02-16 | Pinecrest Cardiovascular Associates | $610.00 | 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.