Professional claim · CMS-1500 · EDI 837P
CLM-2026-008471
Lakeside Medical Group, Internal Medicine. Service 2026-03-22 at office (POS 11). Received 2026-04-24.
Approved
Billed
$96.00
1 line
Allowed
$59.52
contract rate applied
Plan pays
$29.52
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Rebecca Bennett
- Member ID
- UHC-24020-26
- Date of birth
- 1961-04-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427903
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-7714
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,305.88 of $1,500.0087%
- Out-of-pocket maximum
- $2,865.58 of $6,000.0048%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 8815147649
- Location
- Tampa, FL · TIN 85-1984822
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $96.00 | $59.52 | $30.00 | $29.52 | Paid |
| Totals | $96.00 | $59.52 | $30.00 | $29.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-951476
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027422 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: N/A (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 33 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 Lakeside Medical Group (3228212296). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-03-22 14:03
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$96.00
Plan discount
$36.48
contracted rate
Plan paid
$29.52
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
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.