Professional claim · CMS-1500 · EDI 837P
CLM-2026-010444
Mesa Diabetes Center, Endocrinology. Service 2026-01-17 at office (POS 11). Received 2026-02-24.
Approved
Billed
$531.00
2 lines
Allowed
$329.22
contract rate applied
Plan pays
$289.22
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Frances Long
- Member ID
- none on golden record
- Date of birth
- 1959-08-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422554
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-5916
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,384.39 of $2,500.0055%
- Out-of-pocket maximum
- $2,295.97 of $10,000.0023%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 2879027987
- Location
- Scottsdale, AZ · TIN 19-2073831
- Authorisation / referral
- none / REF619692
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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $174.00 | $107.88 | $40.00 | $67.88 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $357.00 | $221.34 | $0.00 | $221.34 | Paid |
| Totals | $531.00 | $329.22 | $40.00 | $289.22 | ||||||
Diagnoses (ICD-10-CM)
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
Claim header
- Patient account
- PA-378894
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015660 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-01-17: NAVIGATE-HMO (HMO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 Mesa Diabetes Center (3634244123). | |
| 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: Mesa Diabetes Center2026-01-17 10:01
Patient seen for hypothyroidism, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$531.00
Plan discount
$201.78
contracted rate
Plan paid
$289.22
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2026-01-17: NAVIGATE-HMO (HMO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026020 | 2026-05-11 | Riverside Community Hospital | $1,821.00 | Approved |
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.