Professional claim · CMS-1500 · EDI 837P
CLM-2026-011315
Heritage Medical Group, Internal Medicine. Service 2026-02-09 at office (POS 11). Received 2026-03-15.
Approved
Billed
$411.00
2 lines
Allowed
$254.82
contract rate applied
Plan pays
$234.82
approved
Member owes
$20.00
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
- Frank Padilla
- Member ID
- UHC-18739-54
- Date of birth
- 1964-02-14
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-405260
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3480
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,729.38 of $3,500.0049%
- Out-of-pocket maximum
- $4,676.32 of $14,000.0033%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 6520178909
- Location
- Denver, CO · TIN 85-4450273
- Authorisation / referral
- none / REF513903
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 | $353.00 | $218.86 | $20.00 | $198.86 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $58.00 | $35.96 | $0.00 | $35.96 | Paid |
| Totals | $411.00 | $254.82 | $20.00 | $234.82 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
Claim header
- Patient account
- PA-395374
- 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-019806 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-09: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 34 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 Heritage Medical Group (9350331127). | |
| 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: Heritage Medical Group2026-02-09 14:48
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$411.00
Plan discount
$156.18
contracted rate
Plan paid
$234.82
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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018021 | 2026-08-04 | Pinecrest Behavioral Health | $220.00 | Needs review |
| CLM-2026-018020 | 2026-08-04 | Sunrise Counseling Center | $220.00 | Approved |
| CLM-2026-008010 | 2026-07-12 | Heritage Imaging Center | $374.00 | Approved |
| CLM-2026-024733 | 2026-04-24 | Riverside Orthopedic Specialists | $8,953.00 | Denied |
| CLM-2026-030057 | 2026-02-26 | Riverside Internal Medicine Associates | $222.00 | Denied |
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.