Professional claim · CMS-1500 · EDI 837P
CLM-2026-002917
Heritage Family Practice, Family Medicine. Service 2026-08-29 at office (POS 11). Received 2026-10-02.
Approved
Billed
$196.00
1 line
Allowed
$121.52
contract rate applied
Plan pays
$81.52
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Sarah Cole
- Member ID
- UHC-95165-36
- Date of birth
- 1953-06-18
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-410379
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0730
- Coverage period
- 2021-03-01 to present
- Deductible
- $918.32 of $2,500.0037%
- Out-of-pocket maximum
- $2,073.53 of $10,000.0021%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 4069954921
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $196.00 | $121.52 | $40.00 | $81.52 | Paid |
| Totals | $196.00 | $121.52 | $40.00 | $81.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-654704
- 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-002565 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-29: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 34 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 Practice2026-08-29 14:03
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$196.00
Plan discount
$74.48
contracted rate
Plan paid
$81.52
You may owe
$40.00
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-2026-027259 | 2026-04-24 | Lakeside Regional Medical Center | $2,655.00 | 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.