Professional claim · CMS-1500 · EDI 837P
CLM-2026-007984
Heritage Internal Medicine Associates, Internal Medicine. Service 2025-12-29 at office (POS 11). Received 2026-01-21.
Approved
Billed
$485.00
2 lines
Allowed
$300.70
contract rate applied
Plan pays
$280.70
approved
Member owes
$20.00
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
- Mason Jacobs
- Member ID
- UHC-48090-22
- Date of birth
- 1988-12-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426446
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2411
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,391.11 of $3,500.0040%
- Out-of-pocket maximum
- $681.39 of $10,500.006%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 7246859541
- Location
- Miami, FL · TIN 57-4041631
- 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 | $20.00 | $240.40 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $65.00 | $40.30 | $0.00 | $40.30 | Paid |
| Totals | $485.00 | $300.70 | $20.00 | $280.70 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-125491
- 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-004319 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-29: SELECT-EPO (EPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 23 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 Internal Medicine Associates (6689259359). | |
| 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 Internal Medicine Associates2025-12-29 14:06
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$485.00
Plan discount
$184.30
contracted rate
Plan paid
$280.70
You may owe
$20.00
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-2026-017398 | 2025-12-31 | Heritage Internal Medicine Associates | $303.00 | Approved |
| CLM-2026-006894 | 2025-12-05 | Desert Heart Institute | $958.00 | 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.