Professional claim · CMS-1500 · EDI 837P
CLM-2026-007084
Desert Diabetes Center, Endocrinology. Service 2026-02-25 at office (POS 11). Received 2026-04-01.
Approved
Billed
$599.00
2 lines
Allowed
$371.38
contract rate applied
Plan pays
$296.38
approved
Member owes
$75.00
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
- Deborah Hughes
- Member ID
- UHC-56499-04
- Date of birth
- 1956-01-10
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-430934
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5846
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,212.08 of $3,500.0035%
- Out-of-pocket maximum
- $4,933.07 of $10,500.0047%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 4240293520
- Location
- Phoenix, AZ · TIN 51-1868485
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $420.00 | $260.40 | $75.00 | $185.40 | Paid |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $179.00 | $110.98 | $0.00 | $110.98 | Paid |
| Totals | $599.00 | $371.38 | $75.00 | $296.38 | ||||||
Diagnoses (ICD-10-CM)
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
Claim header
- Patient account
- PA-241934
- 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-023416 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-25: OPTIONS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 35 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 Diabetes Center (4143565768). | |
| 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 Diabetes Center2026-02-25 11:27
Patient seen for hypothyroidism, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$599.00
Plan discount
$227.62
contracted rate
Plan paid
$296.38
You may owe
$75.00
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-2026-007085 | 2026-02-25 | Desert Diabetes Center | $599.00 | 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.