Professional claim · CMS-1500 · EDI 837P
CLM-2026-005649
Mesa Diabetes Center, Endocrinology. Service 2026-05-21 at office (POS 11). Received 2026-06-18.
Approved
Billed
$606.00
2 lines
Allowed
$375.72
contract rate applied
Plan pays
$325.72
approved
Member owes
$50.00
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
- Bryan Ferguson
- Member ID
- UHC-51134-40
- Date of birth
- 1977-11-06
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-413739
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2075
- Coverage period
- 2024-11-01 to present
- Deductible
- $387.65 of $500.0078%
- Out-of-pocket maximum
- $725.38 of $1,500.0048%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 2605910464
- Location
- Scottsdale, AZ · TIN 19-2073831
- 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 | $296.00 | $183.52 | $50.00 | $133.52 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $310.00 | $192.20 | $0.00 | $192.20 | Paid |
| Totals | $606.00 | $375.72 | $50.00 | $325.72 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-417082
- 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-023502 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-21: CHOICE-PLUS-PPO (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 28 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 Mesa Diabetes Center (3634244123). | |
| 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: Mesa Diabetes Center2026-05-21 13:44
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$606.00
Plan discount
$230.28
contracted rate
Plan paid
$325.72
You may owe
$50.00
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-2026-017794 | 2026-09-01 | Riverside Regional Medical Center | $1,049.00 | Approved |
| CLM-2026-030665 | 2026-03-04 | Meadow Medical Group | $38.00 | 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.