Professional claim · CMS-1500 · Provider portal
CLM-2026-003266
Evergreen Family Practice, Family Medicine. Service 2026-01-01 at office (POS 11). Received 2026-02-10.
Approved
Billed
$224.00
3 lines
Allowed
$138.88
contract rate applied
Plan pays
$113.88
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
- Abigail Reynolds
- Member ID
- UHC-56842-65
- Date of birth
- 1976-04-27
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-410106
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2002
- Coverage period
- 2025-06-01 to present
- Deductible
- $295.74 of $1,000.0030%
- Out-of-pocket maximum
- $446.61 of $2,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 5936583900
- Location
- Los Angeles, CA · TIN 10-4370039
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $158.00 | $97.96 | $25.00 | $72.96 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $24.00 | $14.88 | $0.00 | $14.88 | Paid |
| Totals | $224.00 | $138.88 | $25.00 | $113.88 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-874251
- 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-011939 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-01: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 40 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 Evergreen Family Practice (1600303576). | |
| 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: Evergreen Family Practice2026-01-01 18:33
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$224.00
Plan discount
$85.12
contracted rate
Plan paid
$113.88
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-2026-016997 | 2026-09-14 | Canyon Clinical Laboratories | $104.00 | Needs review |
| CLM-2026-016850 | 2026-07-22 | Mesa Orthopedic Specialists | $430.00 | 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.