Professional claim · CMS-1500 · EDI 837P
CLM-2026-011457
Unity Medical Group, Family Medicine. Service 2026-04-17 at office (POS 11). Received 2026-04-30.
Denied
Billed
$176.00
1 line
Allowed
$109.12
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Sean Chapman
- Member ID
- UHC-35561-40
- Date of birth
- 2002-02-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420830
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0949
- Coverage period
- 2021-06-01 to 2026-04-12
- Deductible
- $653.69 of $1,500.0044%
- Out-of-pocket maximum
- $2,674.14 of $6,000.0045%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6749849405
- Network
- In network
- Rendering NPI
- 4863895262
- Location
- Houston, TX · TIN 69-3600999
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $176.00 | $109.12 | — | — | DeniedCO27 |
| Totals | $176.00 | $109.12 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-979303
- 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-028421 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-17 is after coverage terminated on 2026-04-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 13 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 Unity Medical Group (6749849405). | |
| 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. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Medical Group2026-04-17 15:24
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-04-30 05:27
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-17 is after coverage terminated on 2026-04-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004844 | 2026-10-09 | Canyon Primary Care Associates | $587.00 | Denied |
| CLM-2026-026325 | 2026-08-31 | Lakeside Imaging Center | $234.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.