Claims workbench/CLM-2026-005661
Professional claim · CMS-1500 · Paper

CLM-2026-005661

Sunrise Medical Group, Family Medicine. Service 2026-02-27 at office (POS 11). Received 2026-03-14.

Approved
Billed
$270.00
1 line
Allowed
$167.40
contract rate applied
Plan pays
$147.40
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Madison Lopez
Member ID
UHC-62337-01
Date of birth
1970-08-17
Identity
Verified6 records, confidence 0.99
Claim record
CLMCLM-408208
Relationship
Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan
UNKNOWN PPO group GRP-3135
Coverage period
2023-11-01 to present
Deductible
$669.23 of $2,500.0027%
Out-of-pocket maximum
$3,159.56 of $7,500.0042%
Copays
office $20.00, specialist $50.00, emergency $350.00
Physical therapy visits
0 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
7750705916
Network
In network
Rendering NPI
5419377614
Location
Tampa, FL · TIN 44-4657025
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199395Preventive visit, 18-39 years—11$270.00$167.40$20.00$147.40Paid
Totals$270.00$167.40$20.00$147.40
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-749232
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

CheckResultCodeDetail
Member identityPassAttached to MBR-011442 (verified, link confidence 0.99).
EligibilityPassActive on 2026-02-27: UNKNOWN (PPO), effective 2023-11-01.
Timely filingPassReceived 15 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Medical Group (7750705916).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Sunrise Medical Group2026-02-27 12:18

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$270.00
Plan discount
$102.60
contracted rate
Plan paid
$147.40
You may owe
$20.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0215592026-01-20Heritage Digestive Health Center$2,497.00Approved

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.

Review queueMember identity