Professional claim · CMS-1500 · EDI 837P
CLM-2026-010822
Harbor Medical Group, Internal Medicine. Service 2026-08-30 at office (POS 11). Received 2026-09-20.
ApprovedOut of network
Billed
$370.00
1 line
Allowed
$166.50
contract rate applied
Plan pays
$146.50
approved
Member owes
$20.00
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
- Kyle Li
- Member ID
- UHC-25227-10
- Date of birth
- 1946-05-20
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-409480
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1937
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,011.17 of $2,500.0040%
- Out-of-pocket maximum
- $1,762.11 of $10,000.0018%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 7961219236
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $370.00 | $166.50 | $20.00 | $146.50 | Paid |
| Totals | $370.00 | $166.50 | $20.00 | $146.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-981304
- 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-006617 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-30: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 21 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Medical Group2026-08-30 16:40
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$370.00
Plan discount
$203.50
out-of-network allowance
Plan paid
$146.50
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028227 | 2026-01-12 | Canyon Reference Lab | $179.00 | Denied |
| CLM-2026-028226 | 2026-01-12 | Canyon Reference Lab | $179.00 | 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.