Professional claim · CMS-1500 · EDI 837P
CLM-2026-007519
Heritage Medical Group, Family Medicine. Service 2026-06-26 at office (POS 11). Received 2026-07-14.
ApprovedOut of network
Billed
$409.00
2 lines
Allowed
$184.05
contract rate applied
Plan pays
$154.05
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Charles Walker
- Member ID
- UHC-36240-36
- Date of birth
- 1952-02-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-415795
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6625
- Coverage period
- 2021-06-01 to present
- Deductible
- $373.22 of $3,500.0011%
- Out-of-pocket maximum
- $832.92 of $10,500.008%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 9188003252
- Location
- Denver, CO · TIN 49-9592909
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $234.00 | $105.30 | $30.00 | $75.30 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $175.00 | $78.75 | $0.00 | $78.75 | Paid |
| Totals | $409.00 | $184.05 | $30.00 | $154.05 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-262752
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029399 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-26: CHOICE-PLUS-PPO (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 18 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Heritage Medical Group2026-06-26 09:55
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
$409.00
Plan discount
$224.95
out-of-network allowance
Plan paid
$154.05
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.