Professional claim · CMS-1500 · EDI 837P
CLM-2026-005797
Desert Heart Institute, Cardiology. Service 2026-02-27 at office (POS 11). Received 2026-03-01.
Approved
Billed
$442.00
1 line
Allowed
$274.04
contract rate applied
Plan pays
$224.04
approved
Member owes
$50.00
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
- Randy Nunez
- Member ID
- UHC-77425-69
- Date of birth
- 1979-06-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402969
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5719
- Coverage period
- 2021-01-01 to 2026-05-07
- Deductible
- $3.59 of $1,000.000%
- Out-of-pocket maximum
- $873.84 of $3,000.0029%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 3432785152
- Location
- Mesa, AZ · TIN 39-5178200
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $442.00 | $274.04 | $50.00 | $224.04 | Paid |
| Totals | $442.00 | $274.04 | $50.00 | $224.04 | ||||||
Diagnoses (ICD-10-CM)
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-866686
- 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-001494 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-27: OPTIONS-PPO (PPO), effective 2021-01-01, terms 2026-05-07. | |
| Timely filing | Pass | Received 2 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 Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-02-27 16:43
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$442.00
Plan discount
$167.96
contracted rate
Plan paid
$224.04
You may owe
$50.00
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-2026-024763 | 2026-02-25 | Riverside Primary Care Associates | $174.00 | Needs review |
| CLM-2026-024762 | 2026-02-25 | Riverside Primary Care Associates | $174.00 | 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.