Professional claim · CMS-1500 · EDI 837P
CLM-2026-003839
Valley Medical Group, Family Medicine. Service 2026-09-10 at office (POS 11). Received 2026-10-18.
Approved
Billed
$274.00
2 lines
Allowed
$169.88
contract rate applied
Plan pays
$149.88
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ahmed Wallace
- Member ID
- UHC-37460-16
- Date of birth
- 1970-07-11
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-407178
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3527
- Coverage period
- 2023-08-01 to present
- Deductible
- $273.09 of $500.0055%
- Out-of-pocket maximum
- $279.14 of $1,000.0028%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5938488512
- Network
- In network
- Rendering NPI
- 5730776668
- Location
- Tempe, AZ · TIN 76-2268417
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $240.00 | $148.80 | $20.00 | $128.80 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $34.00 | $21.08 | $0.00 | $21.08 | Paid |
| Totals | $274.00 | $169.88 | $20.00 | $149.88 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-440675
- 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-002083 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-09-10: NULL (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 38 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 Valley Medical Group (5938488512). | |
| 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: Valley Medical Group2026-09-10 14:20
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$274.00
Plan discount
$104.12
contracted rate
Plan paid
$149.88
You may owe
$20.00
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-2026-018860 | 2026-08-23 | Mesa Imaging Center | $2,270.00 | Approved |
| CLM-2026-029820 | 2026-01-27 | Unity Internal Medicine Associates | $305.00 | Approved |
| CLM-2026-024882 | 2025-11-26 | Lakeside Heart Institute | $8,113.00 | Approved |
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.