Claims workbench/CLM-2026-003180
Professional claim · CMS-1500 · EDI 837P

CLM-2026-003180

Heritage GI Associates, Gastroenterology. Service 2026-08-19 at office (POS 11). Received 2026-09-27.

Approved
Billed
$327.00
1 line
Allowed
$202.74
contract rate applied
Plan pays
$127.74
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
Nancy Spencer
Member ID
UHC-62462-17
Date of birth
2008-09-06
Identity
Verified3 records, confidence 0.96
Claim record
CLMCLM-406855
Relationship
Self, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-0565
Coverage period
2021-12-01 to present
Deductible
$1,489.14 of $2,500.0060%
Out-of-pocket maximum
$138.58 of $5,000.003%
Copays
office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Heritage GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI
8459983820
Network
In network
Rendering NPI
1292784638
Location
Tempe, AZ · TIN 81-8461121
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$327.00$202.74$75.00$127.74Paid
Totals$327.00$202.74$75.00$127.74
Diagnoses (ICD-10-CM)
  • 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
  • 2. R10.13 Epigastric pain
Claim header
Patient account
PA-544776
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-005070 (verified, link confidence 0.96).
EligibilityPassActive on 2026-08-19: MEDICARE-ADV-B (MA), effective 2021-12-01.
Timely filingPassReceived 39 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage GI Associates (8459983820).
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: Heritage GI Associates2026-08-19 12:55

    Established patient presents with encounter for screening for malignant neoplasm of colon; 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
$327.00
Plan discount
$124.26
contracted rate
Plan paid
$127.74
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