Professional claim · CMS-1500 · EDI 837P
CLM-2026-006673
Riverside Primary Care Associates, Family Medicine. Service 2026-07-29 at office (POS 11). Received 2026-08-26.
Approved
Billed
$242.00
2 lines
Allowed
$150.04
contract rate applied
Plan pays
$133.92
approved
Member owes
$16.12
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Mason Robertson
- Member ID
- UHC-22924-14
- Date of birth
- 1991-12-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423824
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6817
- Coverage period
- 2022-10-01 to present
- Deductible
- $400.08 of $1,000.0040%
- Out-of-pocket maximum
- $102.60 of $4,000.003%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8662496362
- Network
- In network
- Rendering NPI
- 3742376668
- Location
- Austin, TX · TIN 71-8699033
- 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 | $26.00 | $16.12 | $16.12 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $216.00 | $133.92 | $0.00 | $133.92 | Paid |
| Totals | $242.00 | $150.04 | $16.12 | $133.92 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-338313
- 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-028536 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-29: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 28 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 Riverside Primary Care Associates (8662496362). | |
| 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: Riverside Primary Care Associates2026-07-29 15:58
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$242.00
Plan discount
$91.96
contracted rate
Plan paid
$133.92
You may owe
$16.12
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
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.