Claims workbench/CLM-2026-003081
Professional claim · CMS-1500 · EDI 837P

CLM-2026-003081

Desert Heart Institute, Cardiology. Service 2026-07-27 at office (POS 11). Received 2026-09-09.

Approved
Billed
$335.00
1 line
Allowed
$207.70
contract rate applied
Plan pays
$132.70
approved
Member owes
$75.00
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
Michelle Butler
Member ID
UHC-40493-92
Date of birth
2006-04-03
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-424310
Relationship
Child, Dallas, TX

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-5556
Coverage period
2024-05-01 to present
Deductible
$97.12 of $500.0019%
Out-of-pocket maximum
$69.43 of $2,000.003%
Copays
office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits
6 of 20 used

Provider

Billing and rendering

Billing provider
Desert Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
5901282678
Network
In network
Rendering NPI
7037574606
Location
Mesa, AZ · TIN 39-5178200
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$335.00$207.70$75.00$132.70Paid
Totals$335.00$207.70$75.00$132.70
Diagnoses (ICD-10-CM)
  • 1. I48.91 Unspecified atrial fibrillationprincipal
  • 2. I50.9 Heart failure, unspecified
Claim header
Patient account
PA-632328
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

CheckResultCodeDetail
Member identityPassAttached to MBR-002758 (verified, link confidence 1.00).
EligibilityPassActive on 2026-07-27: OPTIONS-PPO (PPO), effective 2024-05-01.
Timely filingPassReceived 44 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Heart Institute (5901282678).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Desert Heart Institute2026-07-27 11:21

    Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$335.00
Plan discount
$127.30
contracted rate
Plan paid
$132.70
You may owe
$75.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity