Claims workbench/CLM-2026-008580

Professional claim · CMS-1500 · EDI 837P

CLM-2026-008580

Mesa Primary Care Associates, Family Medicine. Service 2025-12-24 at office (POS 11). Received 2026-01-07.

Approved

Billed

$311.00

1 line

Allowed

$192.82

contract rate applied

Plan pays

$172.82

approved

Member owes

$20.00

copay / deductible / 20% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Hannah Nelson
Member ID: UHC-54516-18
Date of birth: 1987-03-10
Identity: Verified5 records, confidence 0.93
Claim record: CLMCLM-428511
Relationship: Spouse, Tampa, FL

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-5702
Coverage period: 2022-07-01 to present
Deductible: $1,323.51 of $3,500.0038%
Out-of-pocket maximum: $2,824.81 of $10,500.0027%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Mesa Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 1256425335
Network: In network
Rendering NPI: 6831946820
Location: Nashville, TN · TIN 57-2751445
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	99214	Office visit, established patient, moderate complexity	—	1	1	$311.00	$192.82	$20.00	$172.82	Paid
Totals						$311.00	$192.82	$20.00	$172.82

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. E11.9 Type 2 diabetes mellitus without complications
3. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-630935
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	Detail
Member identity	Pass	Attached to MBR-002099 (verified, link confidence 0.93).
Eligibility	Pass	Active on 2025-12-24: CHOICE-PLUS-PPO (PPO), effective 2022-07-01.
Timely filing	Pass	Received 14 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 Primary Care Associates (1256425335).
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 Primary Care Associates2025-12-24 16:48
Patient seen for low back pain, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-01-07 00:54
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-07 10:34
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-630935.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.

Explanation of benefits

What the member will see

Amount billed

$311.00

Plan discount

$118.18

contracted rate

Plan paid

$172.82

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 13:43
Clean claim.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-033743	2026-06-03	Pinecrest Internal Medicine Associates	$90.00	Approved
CLM-2026-006041	2026-02-07	Sunrise Imaging Center	$2,525.00	Needs review

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity