Professional claim · CMS-1500 · EDI 837P
CLM-2026-005897
Mesa Family Practice, Family Medicine. Service 2026-06-29 at office (POS 11). Received 2026-07-08.
Approved
Billed
$230.00
2 lines
Allowed
$142.60
contract rate applied
Plan pays
$117.60
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Michelle Bowman
- Member ID
- UHC-64949-34
- Date of birth
- 1971-10-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-430943
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4449
- Coverage period
- 2023-04-01 to present
- Deductible
- $340.99 of $1,000.0034%
- Out-of-pocket maximum
- $583.56 of $2,000.0029%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8314374140
- Network
- In network
- Rendering NPI
- 7167547182
- Location
- Atlanta, GA · TIN 41-8917438
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $203.00 | $125.86 | $25.00 | $100.86 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $27.00 | $16.74 | $0.00 | $16.74 | Paid |
| Totals | $230.00 | $142.60 | $25.00 | $117.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-146463
- 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-013784 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 9 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 Family Practice (8314374140). | |
| 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 Family Practice2026-06-29 14:19
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$230.00
Plan discount
$87.40
contracted rate
Plan paid
$117.60
You may owe
$25.00
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-2026-020538 | 2026-03-19 | Northgate Reference Lab | $38.00 | Approved |
| CLM-2026-017527 | 2026-02-14 | Harbor Rehabilitation Center | $314.00 | Denied |
| CLM-2026-005025 | 2026-01-07 | Valley Primary Care Associates | $546.00 | 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.