Professional claim · CMS-1500 · EDI 837P
CLM-2026-010989
Pinecrest GI Associates, Gastroenterology. Service 2026-07-25 at office (POS 11). Received 2026-09-05.
Approved
Billed
$234.00
1 line
Allowed
$145.08
contract rate applied
Plan pays
$95.08
approved
Member owes
$50.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Melissa Alexander
- Member ID
- UHC-11511-21
- Date of birth
- 1944-12-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-400776
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2708
- Coverage period
- 2024-02-01 to present
- Deductible
- $166.54 of $1,000.0017%
- Out-of-pocket maximum
- $686.65 of $2,000.0034%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 1725394203
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- none / REF246867
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 | $234.00 | $145.08 | $50.00 | $95.08 | Paid |
| Totals | $234.00 | $145.08 | $50.00 | $95.08 | ||||||
Diagnoses (ICD-10-CM)
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
Claim header
- Patient account
- PA-606100
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032158 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-25: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 42 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 Pinecrest GI Associates (3588910497). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest GI Associates2026-07-25 10:50
Patient seen for epigastric pain.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$234.00
Plan discount
$88.92
contracted rate
Plan paid
$95.08
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005838 | 2026-06-13 | Northgate Medical Group | $219.00 | 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.