Professional claim · CMS-1500 · EDI 837P
CLM-2026-010141
Riverside Primary Care Associates, Family Medicine. Service 2026-08-26 at office (POS 11). Received 2026-10-06.
Approved
Billed
$253.00
2 lines
Allowed
$156.86
contract rate applied
Plan pays
$126.86
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
- James Hanson
- Member ID
- UHC-90765-54
- Date of birth
- 1984-11-23
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-422274
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0887
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,886.66 of $2,500.0075%
- Out-of-pocket maximum
- $669.15 of $10,000.007%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6269804525
- Network
- In network
- Rendering NPI
- 3382057404
- Location
- Los Angeles, CA · TIN 64-8796526
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $239.00 | $148.18 | $30.00 | $118.18 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $14.00 | $8.68 | $0.00 | $8.68 | Paid |
| Totals | $253.00 | $156.86 | $30.00 | $126.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-801447
- 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-005594 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-26: MEDICARE-ADV-A (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 41 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 Riverside Primary Care Associates (6269804525). | |
| 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: Riverside Primary Care Associates2026-08-26 09:24
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$253.00
Plan discount
$96.14
contracted rate
Plan paid
$126.86
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-2026-010142 | 2026-08-26 | Riverside Primary Care Associates | $253.00 | Needs review |
| CLM-2026-025406 | 2026-06-13 | Northgate Reference Lab | $75.00 | Approved |
| CLM-2026-002793 | 2026-04-22 | Northgate Internal Medicine Associates | $375.00 | Approved |
| CLM-2026-015207 | 2026-05-16 | Meadow Heart Institute | $925.00 | Approved |
| CLM-2026-002187 | 2026-02-28 | Unity Digestive Health Center | $1,736.00 | 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.