Professional claim · CMS-1500 · EDI 837P
CLM-2026-003123
Riverside Primary Care Associates, Family Medicine. Service 2026-03-21 at office (POS 11). Received 2026-04-23.
Approved
Billed
$211.00
2 lines
Allowed
$130.82
contract rate applied
Plan pays
$119.04
approved
Member owes
$11.78
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
- Daniel Pena
- Member ID
- UHC-54987-16
- Date of birth
- 1971-01-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432298
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group NULL
- Coverage period
- 2021-07-01 to present
- Deductible
- $844.67 of $3,500.0024%
- Out-of-pocket maximum
- $946.51 of $10,500.009%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8662496362
- Network
- In network
- Rendering NPI
- 5711347455
- Location
- Austin, TX · TIN 71-8699033
- 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 | 36415 | Venipuncture | — | 1 | 1 | $19.00 | $11.78 | $11.78 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $192.00 | $119.04 | $0.00 | $119.04 | Paid |
| Totals | $211.00 | $130.82 | $11.78 | $119.04 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-785466
- 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-027341 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-21: UNKNOWN (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 33 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 Riverside Primary Care Associates (8662496362). | |
| 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: Riverside Primary Care Associates2026-03-21 09:33
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$211.00
Plan discount
$80.18
contracted rate
Plan paid
$119.04
You may owe
$11.78
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
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.