Claims workbench/CLM-2026-007380
Professional claim · CMS-1500 · EDI 837P

CLM-2026-007380

Summit Heart Institute, Cardiology. Service 2026-04-06 at office (POS 11). Received 2026-05-21.

Approved
Billed
$424.00
1 line
Allowed
$262.88
contract rate applied
Plan pays
$187.88
approved
Member owes
$75.00
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
Alan Diaz
Member ID
UHC-23825-89
Date of birth
1979-12-10
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-404047
Relationship
Self, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-6843
Coverage period
2022-04-01 to present
Deductible
$295.29 of $1,500.0020%
Out-of-pocket maximum
$998.48 of $4,500.0022%
Copays
office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits
14 of 20 used

Provider

Billing and rendering

Billing provider
Summit Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
1318552993
Network
In network
Rendering NPI
9591855389
Location
Tampa, FL · TIN 24-2775289
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193224Holter monitor, 48 hours—11$424.00$262.88$75.00$187.88Paid
Totals$424.00$262.88$75.00$187.88
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-861688
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

CheckResultCodeDetail
Member identityPassAttached to MBR-028618 (verified, link confidence 0.99).
EligibilityPassActive on 2026-04-06: SELECT-EPO (EPO), effective 2022-04-01.
Timely filingPassReceived 45 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Heart Institute (1318552993).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Summit Heart Institute2026-04-06 09:43

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$424.00
Plan discount
$161.12
contracted rate
Plan paid
$187.88
You may owe
$75.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0073812026-04-06Summit Heart Institute$424.00Needs review
CLM-2026-0249452026-03-30Northgate Reference Lab$104.00Approved

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.

Review queueMember identity