Claims workbench/CLM-2026-010249
Professional claim · CMS-1500 · EDI 837P

CLM-2026-010249

Mesa Diabetes Center, Endocrinology. Service 2026-03-16 at office (POS 11). Received 2026-04-25.

Approved
Billed
$336.00
1 line
Allowed
$208.32
contract rate applied
Plan pays
$148.32
approved
Member owes
$60.00
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
Anthony Burton
Member ID
UHC-76511-82
Date of birth
1955-11-09
Identity
Verified2 records, confidence 0.96
Claim record
CLMCLM-410729
Relationship
Child

Coverage and accumulators

Found by member ID

Plan
NULL PPO group GRP-1863
Coverage period
2025-02-01 to present
Deductible
$346.52 of $500.0069%
Out-of-pocket maximum
$235.01 of $1,000.0024%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
6 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Diabetes Center
Endocrinology · taxonomy 207RE0101X
NPI
2446853584
Network
In network
Rendering NPI
7672973949
Location
Denver, CO · TIN 89-4122070
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199215Office visit, established patient, high complexity—11$336.00$208.32$60.00$148.32Paid
Totals$336.00$208.32$60.00$148.32
Diagnoses (ICD-10-CM)
  • 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
  • 2. E03.9 Hypothyroidism, unspecified
Claim header
Patient account
PA-467697
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-000616 (verified, link confidence 0.96).
EligibilityPassActive on 2026-03-16: NULL (PPO), effective 2025-02-01.
Timely filingPassReceived 40 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Diabetes Center (2446853584).
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: Mesa Diabetes Center2026-03-16 12:06

    Established patient presents with thyrotoxicosis, unspecified; 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
$336.00
Plan discount
$127.68
contracted rate
Plan paid
$148.32
You may owe
$60.00
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