Claims workbench/CLM-2026-009955
Professional claim · CMS-1500 · EDI 837P

CLM-2026-009955

Unity Digestive Health Center, Gastroenterology. Service 2026-07-04 at office (POS 11). Received 2026-07-19.

Approved
Billed
$266.00
1 line
Allowed
$164.92
contract rate applied
Plan pays
$114.92
approved
Member owes
$50.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Wayne Young
Member ID
UHC-32326-81
Date of birth
2003-07-25
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-404920
Relationship
Self, Austin, TX

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-9327
Coverage period
2021-01-01 to present
Deductible
$1,036.42 of $2,500.0041%
Out-of-pocket maximum
$3,144.80 of $7,500.0042%
Copays
office $20.00, specialist $50.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Unity Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
7402154927
Network
In network
Rendering NPI
7258873547
Location
Denver, CO · TIN 51-9644882
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$266.00$164.92$50.00$114.92Paid
Totals$266.00$164.92$50.00$114.92
Diagnoses (ICD-10-CM)
  • 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
  • 2. R10.13 Epigastric pain
Claim header
Patient account
PA-668344
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

CheckResultCodeDetail
Member identityPassAttached to MBR-038977 (verified, link confidence 0.99).
EligibilityPassActive on 2026-07-04: OPTIONS-PPO (PPO), effective 2021-01-01.
Timely filingPassReceived 15 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Digestive Health Center (7402154927).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Unity Digestive Health Center2026-07-04 18:37

    Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$266.00
Plan discount
$101.08
contracted rate
Plan paid
$114.92
You may owe
$50.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean 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.

Review queueMember identity