Professional claim · CMS-1500 · EDI 837P
CLM-2026-008897
Evergreen Medical Group, Internal Medicine. Service 2026-01-18 at office (POS 11). Received 2026-02-08.
ApprovedOut of network
Billed
$429.00
2 lines
Allowed
$193.05
contract rate applied
Plan pays
$169.20
approved
Member owes
$23.85
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jack Moreno
- Member ID
- UHC-62742-88
- Date of birth
- 1973-04-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424035
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2495
- Coverage period
- 2023-05-01 to present
- Deductible
- $412.41 of $3,500.0012%
- Out-of-pocket maximum
- $3,679.26 of $10,500.0035%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 1208050231
- Location
- Denver, CO · TIN 29-0340886
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $53.00 | $23.85 | $23.85 | $0.00 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $376.00 | $169.20 | $0.00 | $169.20 | Paid |
| Totals | $429.00 | $193.05 | $23.85 | $169.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-711155
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011520 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-18: MEDICARE-ADV-B (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 21 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Medical Group2026-01-18 13:45
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$429.00
Plan discount
$235.95
out-of-network allowance
Plan paid
$169.20
You may owe
$23.85
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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.