Professional claim · CMS-1500 · EDI 837P
CLM-2026-011423
Summit Cardiovascular Associates, Cardiology. Service 2026-09-25 at office (POS 11). Received 2026-10-11.
Approved
Billed
$747.00
2 lines
Allowed
$463.14
contract rate applied
Plan pays
$403.14
approved
Member owes
$60.00
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
- Roy Butler
- Member ID
- UHC-83875-27
- Date of birth
- 1986-02-23
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-420669
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4932
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,051.66 of $2,500.0042%
- Out-of-pocket maximum
- $23.10 of $7,500.000%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 3759389174
- Location
- Houston, TX · TIN 53-6389420
- 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 | $280.00 | $173.60 | $60.00 | $113.60 | Paid |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 2 | $467.00 | $289.54 | $0.00 | $289.54 | Paid |
| Totals | $747.00 | $463.14 | $60.00 | $403.14 | ||||||
Diagnoses (ICD-10-CM)
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
Claim header
- Patient account
- PA-703821
- 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-036432 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-09-25: CHOICE-PLUS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 16 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 Summit Cardiovascular Associates (5138686964). | |
| 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: Summit Cardiovascular Associates2026-09-25 16:32
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$747.00
Plan discount
$283.86
contracted rate
Plan paid
$403.14
You may owe
$60.00
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-2026-011424 | 2026-09-25 | Summit Heart Institute | $747.00 | Needs review |
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.