Professional claim · CMS-1500 · EDI 837P
CLM-2026-004429
Harbor Primary Care Associates, Family Medicine. Service 2026-08-05 at office (POS 11). Received 2026-09-13.
Approved
Billed
$349.00
2 lines
Allowed
$216.38
contract rate applied
Plan pays
$176.38
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Paul Russell
- Member ID
- UHC-55726-01
- Date of birth
- 1988-05-04
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-400132
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7583
- Coverage period
- 2023-03-01 to present
- Deductible
- $450.26 of $1,500.0030%
- Out-of-pocket maximum
- $885.24 of $4,500.0020%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6839311837
- Network
- In network
- Rendering NPI
- 6194135565
- Location
- Minneapolis, MN · TIN 50-2546964
- 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 | $316.00 | $195.92 | $40.00 | $155.92 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $33.00 | $20.46 | $0.00 | $20.46 | Paid |
| Totals | $349.00 | $216.38 | $40.00 | $176.38 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-168156
- 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-013147 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: SELECT-EPO (EPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 39 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 Harbor Primary Care Associates (6839311837). | |
| 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: Harbor Primary Care Associates2026-08-05 17:55
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
$349.00
Plan discount
$132.62
contracted rate
Plan paid
$176.38
You may owe
$40.00
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-2026-020741 | 2026-09-28 | Desert Regional Medical Center | $1,476.00 | Needs review |
| CLM-2026-022840 | 2026-08-27 | Lakeside Clinical Laboratories | $119.00 | Approved |
| CLM-2026-020432 | 2026-07-13 | Riverside Cardiovascular Associates | $644.00 | 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.