Professional claim · CMS-1500 · EDI 837P
CLM-2026-005875
Desert Medical Group, Internal Medicine. Service 2026-06-13 at office (POS 11). Received 2026-06-28.
Approved
Billed
$359.00
2 lines
Allowed
$222.58
contract rate applied
Plan pays
$192.58
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Amber Lee
- Member ID
- UHC-32742-91
- Date of birth
- 2004-04-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427623
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4648
- Coverage period
- 2021-06-01 to present
- Deductible
- $1,357.98 of $2,500.0054%
- Out-of-pocket maximum
- $522.26 of $5,000.0010%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5303428622
- Network
- In network
- Rendering NPI
- 4994093779
- Location
- Atlanta, GA · TIN 67-2719316
- 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 | $308.00 | $190.96 | $30.00 | $160.96 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $51.00 | $31.62 | $0.00 | $31.62 | Paid |
| Totals | $359.00 | $222.58 | $30.00 | $192.58 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
Claim header
- Patient account
- PA-743817
- 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-000268 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-13: SELECT-EPO (EPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 15 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 Medical Group (5303428622). | |
| 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: Desert Medical Group2026-06-13 18:42
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$359.00
Plan discount
$136.42
contracted rate
Plan paid
$192.58
You may owe
$30.00
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-2026-005364 | 2025-11-23 | Heritage Family Practice | $2,457.00 | Needs review |
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.