Professional claim · CMS-1500 · EDI 837P
CLM-2026-006918
Heritage Primary Care Associates, Family Medicine. Service 2026-08-07 at office (POS 11). Received 2026-08-31.
Approved
Billed
$293.00
2 lines
Allowed
$181.66
contract rate applied
Plan pays
$155.00
approved
Member owes
$26.66
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
- Ruth Stephens
- Member ID
- UHC-49733-39
- Date of birth
- 1956-11-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-405840
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1630
- Coverage period
- 2021-01-01 to present
- Deductible
- $25.62 of $500.005%
- Out-of-pocket maximum
- $269.75 of $1,000.0027%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2218360602
- Network
- In network
- Rendering NPI
- 3401099106
- Location
- Atlanta, GA · TIN 79-7884821
- 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 | $43.00 | $26.66 | $26.66 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $250.00 | $155.00 | $0.00 | $155.00 | Paid |
| Totals | $293.00 | $181.66 | $26.66 | $155.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-915908
- 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-002384 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-07: SELECT-EPO (EPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 24 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 Heritage Primary Care Associates (2218360602). | |
| 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: Heritage Primary Care Associates2026-08-07 11:28
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$293.00
Plan discount
$111.34
contracted rate
Plan paid
$155.00
You may owe
$26.66
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-2026-027923 | 2026-07-26 | Heritage Medical Group | $242.00 | Approved |
| CLM-2026-022865 | 2026-02-24 | Heritage Primary Care Associates | $534.00 | Approved |
| CLM-2026-034014 | 2026-01-05 | Harbor Medical Group | $400.00 | Denied |
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.