Professional claim · CMS-1500 · Provider portal
CLM-2026-009602
Valley Medical Group, Internal Medicine. Service 2026-08-03 at office (POS 11). Received 2026-09-05.
Approved
Billed
$158.00
2 lines
Allowed
$97.96
contract rate applied
Plan pays
$57.96
approved
Member owes
$40.00
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
- Jesse Bennett
- Member ID
- UHC-57219-23
- Date of birth
- 1940-12-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431460
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2611
- Coverage period
- 2021-02-01 to present
- Deductible
- $886.24 of $1,000.0089%
- Out-of-pocket maximum
- $761.62 of $2,000.0038%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 4491993869
- Location
- Nashville, TN · TIN 16-4753822
- 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 | $95.00 | $58.90 | $40.00 | $18.90 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $63.00 | $39.06 | $0.00 | $39.06 | Paid |
| Totals | $158.00 | $97.96 | $40.00 | $57.96 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-476068
- 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-012984 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-03: NULL (PPO), effective 2021-02-01. | |
| 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 Valley Medical Group (1946396904). | |
| 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: Valley Medical Group2026-08-03 09:59
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$158.00
Plan discount
$60.04
contracted rate
Plan paid
$57.96
You may owe
$40.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023994 | 2026-07-22 | Harbor Medical Group | $2,229.00 | Needs review |
| CLM-2026-011676 | 2026-02-22 | Meadow Heart Institute | $6,790.00 | Needs review |
| CLM-2026-034482 | 2026-01-14 | Desert Diagnostic Imaging | $3,419.00 | 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
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.