Professional claim · CMS-1500 · EDI 837P
CLM-2026-005272
Heritage Primary Care Associates, Family Medicine. Service 2026-05-07 at office (POS 11). Received 2026-05-24.
Approved
Billed
$409.00
3 lines
Allowed
$253.58
contract rate applied
Plan pays
$246.14
approved
Member owes
$7.44
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
- Kyle Ward
- Member ID
- UHC-48973-10
- Date of birth
- 1996-05-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406131
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8480
- Coverage period
- 2022-03-01 to present
- Deductible
- $565.42 of $2,500.0023%
- Out-of-pocket maximum
- $452.72 of $5,000.009%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2229159530
- Network
- In network
- Rendering NPI
- 1077096158
- Location
- Houston, TX · TIN 14-5202877
- 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 | $12.00 | $7.44 | $7.44 | $0.00 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $230.00 | $142.60 | $0.00 | $142.60 | Paid |
| 3 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1 | $167.00 | $103.54 | $0.00 | $103.54 | Paid |
| Totals | $409.00 | $253.58 | $7.44 | $246.14 | ||||||
Diagnoses (ICD-10-CM)
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-974184
- 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-014934 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-07: CORE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 17 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 Heritage Primary Care Associates (2229159530). | |
| 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: Heritage Primary Care Associates2026-05-07 18:03
Patient seen for encounter for general adult medical examination without abnormal findings.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$409.00
Plan discount
$155.42
contracted rate
Plan paid
$246.14
You may owe
$7.44
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005273 | 2026-05-07 | Riverside Primary Care Associates | $409.00 | Needs review |
| CLM-2026-019054 | 2026-04-05 | Meadow Physical Therapy | $371.00 | Denied |
| CLM-2026-029611 | 2026-02-05 | Northgate Orthopedic Specialists | $280.00 | 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.