Professional claim · CMS-1500 · EDI 837P
CLM-2026-010530
Harbor Family Practice, Family Medicine. Service 2026-03-03 at office (POS 11). Received 2026-04-09.
Approved
Billed
$532.00
2 lines
Allowed
$329.84
contract rate applied
Plan pays
$289.84
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jeremy Garrett
- Member ID
- UHC-79001-22
- Date of birth
- 1946-10-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431228
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7096
- Coverage period
- 2025-12-01 to present
- Deductible
- $182.35 of $500.0036%
- Out-of-pocket maximum
- $138.28 of $1,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3348247230
- Network
- In network
- Rendering NPI
- 2247236906
- Location
- Austin, TX · TIN 89-3690484
- 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 | $248.00 | $153.76 | $40.00 | $113.76 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $284.00 | $176.08 | $0.00 | $176.08 | Paid |
| Totals | $532.00 | $329.84 | $40.00 | $289.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-247844
- 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-018729 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-03: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 37 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 Harbor Family Practice (3348247230). | |
| 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: Harbor Family Practice2026-03-03 09:17
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$532.00
Plan discount
$202.16
contracted rate
Plan paid
$289.84
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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033972 | 2026-08-23 | Lakeside Clinical Laboratories | $96.00 | Needs review |
| CLM-2026-005605 | 2026-03-08 | Northgate Orthopedic Specialists | $10,241.00 | Needs review |
| CLM-2026-005604 | 2026-03-08 | Northgate Orthopedic Specialists | $10,241.00 | Approved |
| CLM-2026-016077 | 2026-02-11 | Mesa Internal Medicine Associates | $354.00 | 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.