Professional claim · CMS-1500 · EDI 837P
CLM-2026-009830
Meadow Medical Group, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-06-19.
Approved
Billed
$351.00
3 lines
Allowed
$217.62
contract rate applied
Plan pays
$187.62
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ronald Morales
- Member ID
- UHC-99938-63
- Date of birth
- 1948-01-28
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-425713
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8862
- Coverage period
- 2022-12-01 to present
- Deductible
- $375.95 of $2,500.0015%
- Out-of-pocket maximum
- $3,262.66 of $7,500.0044%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7358617562
- Network
- In network
- Rendering NPI
- 2435035151
- Location
- Tempe, AZ · TIN 28-5097821
- 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 | $290.00 | $179.80 | $30.00 | $149.80 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $19.00 | $11.78 | $0.00 | $11.78 | Paid |
| Totals | $351.00 | $217.62 | $30.00 | $187.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-750161
- 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-001108 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-12: OPTIONS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 38 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 Meadow Medical Group (7358617562). | |
| 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: Meadow Medical Group2026-05-12 16:37
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$351.00
Plan discount
$133.38
contracted rate
Plan paid
$187.62
You may owe
$30.00
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-2026-011335 | 2026-08-10 | Desert Internal Medicine Associates | $559.00 | Approved |
| CLM-2026-029623 | 2026-03-08 | Meadow Medical Group | $3,537.00 | 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.