Professional claim · CMS-1500 · Provider portal
CLM-2026-002954
Unity Primary Care Associates, Family Medicine. Service 2026-03-27 at office (POS 11). Received 2026-04-01.
Approved
Billed
$306.00
1 line
Allowed
$189.72
contract rate applied
Plan pays
$164.72
approved
Member owes
$25.00
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
- Amy Sanchez
- Member ID
- UHC-63205-92
- Date of birth
- 1972-07-02
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-432362
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2838
- Coverage period
- 2025-08-01 to present
- Deductible
- $346.42 of $3,500.0010%
- Out-of-pocket maximum
- $5,065.66 of $14,000.0036%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8618575491
- Network
- In network
- Rendering NPI
- 1312724184
- Location
- San Diego, CA · TIN 48-6444371
- 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 | $306.00 | $189.72 | $25.00 | $164.72 | Paid |
| Totals | $306.00 | $189.72 | $25.00 | $164.72 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-265038
- 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-015480 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: CORE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 5 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 Unity Primary Care Associates (8618575491). | |
| 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: Unity Primary Care Associates2026-03-27 11:18
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$306.00
Plan discount
$116.28
contracted rate
Plan paid
$164.72
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-2026-019460 | 2026-05-17 | Riverside Primary Care Associates | $181.00 | Approved |
| CLM-2026-006438 | 2026-04-12 | Lakeside Medical Group | $423.00 | Denied |
| CLM-2026-016108 | 2026-03-10 | Northgate Internal Medicine Associates | $3,324.00 | Needs review |
| CLM-2026-008021 | 2025-08-08 | Northgate Primary Care Associates | $244.00 | Denied |
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.