Professional claim · CMS-1500 · EDI 837P
CLM-2026-010940
Desert Internal Medicine Associates, Internal Medicine. Service 2026-02-09 at office (POS 11). Received 2026-03-20.
Approved
Billed
$479.00
2 lines
Allowed
$296.98
contract rate applied
Plan pays
$271.98
approved
Member owes
$25.00
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
- Linda Green
- Member ID
- UHC-04889-62
- Date of birth
- 1970-08-10
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415617
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7112
- Coverage period
- 2023-04-01 to present
- Deductible
- $586.91 of $1,500.0039%
- Out-of-pocket maximum
- $1,314.15 of $6,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 1306090378
- Location
- Houston, TX · TIN 11-1256116
- 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 | $394.00 | $244.28 | $25.00 | $219.28 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $85.00 | $52.70 | $0.00 | $52.70 | Paid |
| Totals | $479.00 | $296.98 | $25.00 | $271.98 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
Claim header
- Patient account
- PA-590855
- 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-020837 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-09: MEDICARE-ADV-A (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 39 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 Desert Internal Medicine Associates (5106489862). | |
| 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: Desert Internal Medicine Associates2026-02-09 15:35
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$479.00
Plan discount
$182.02
contracted rate
Plan paid
$271.98
You may owe
$25.00
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
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.