Professional claim · CMS-1500 · EDI 837P
CLM-2026-005912
Sunrise Medical Group, Family Medicine. Service 2026-05-16 at office (POS 11). Received 2026-06-22.
Approved
Billed
$31.00
1 line
Allowed
$19.22
contract rate applied
Plan pays
$0.00
approved
Member owes
$19.22
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
- Valentina Daniels
- Member ID
- UHC-13186-78
- Date of birth
- 1995-04-20
- Identity
- Verified4 records, confidence 0.87
- Claim record
- CLMCLM-412349
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2188
- Coverage period
- 2022-02-01 to present
- Deductible
- $360.68 of $500.0072%
- Out-of-pocket maximum
- $649.02 of $2,000.0032%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7750705916
- Network
- In network
- Rendering NPI
- 7728271199
- Location
- Tampa, FL · TIN 44-4657025
- 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 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $19.22 | $19.22 | $0.00 | Paid |
| Totals | $31.00 | $19.22 | $19.22 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-167960
- 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-003344 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-05-16: OPTIONS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 37 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 Sunrise Medical Group (7750705916). | |
| 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: Sunrise Medical Group2026-05-16 17:17
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$31.00
Plan discount
$11.78
contracted rate
Plan paid
$0.00
You may owe
$19.22
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
No other claims.
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.