Professional claim · CMS-1500 · Provider portal
CLM-2026-007742
Mesa Family Practice, Family Medicine. Service 2026-08-04 at office (POS 11). Received 2026-09-09.
Approved
Billed
$234.00
2 lines
Allowed
$145.08
contract rate applied
Plan pays
$120.08
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Billy Wong
- Member ID
- UHC-81240-57
- Date of birth
- 1989-02-21
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420605
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6751
- Coverage period
- 2023-11-01 to present
- Deductible
- $343.10 of $1,500.0023%
- Out-of-pocket maximum
- $903.61 of $6,000.0015%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9198076652
- Network
- In network
- Rendering NPI
- 1519902856
- Location
- Denver, CO · TIN 38-9829181
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $222.00 | $137.64 | $25.00 | $112.64 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $12.00 | $7.44 | $0.00 | $7.44 | Paid |
| Totals | $234.00 | $145.08 | $25.00 | $120.08 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
Claim header
- Patient account
- PA-958551
- 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-007089 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-04: NAVIGATE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Pass | Received 36 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 Mesa Family Practice (9198076652). | |
| 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: Mesa Family Practice2026-08-04 11:19
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$234.00
Plan discount
$88.92
contracted rate
Plan paid
$120.08
You may owe
$25.00
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-2026-028754 | 2026-09-12 | Harbor Reference Lab | $204.00 | Approved |
| CLM-2026-002362 | 2026-07-12 | Heritage Digestive Health Center | $1,778.00 | Approved |
| CLM-2026-031041 | 2026-01-18 | Unity Community Hospital | $688.00 | Approved |
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.