Professional claim · CMS-1500 · EDI 837P
CLM-2026-011538
Canyon Primary Care Associates, Family Medicine. Service 2026-02-25 at office (POS 11). Received 2026-03-13.
Approved
Billed
$359.00
2 lines
Allowed
$222.58
contract rate applied
Plan pays
$202.58
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Frances Hanson
- Member ID
- UHC-45521-79
- Date of birth
- 1989-05-10
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-417970
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1116
- Coverage period
- 2022-01-01 to present
- Deductible
- $335.23 of $1,500.0022%
- Out-of-pocket maximum
- $1,121.00 of $3,000.0037%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4536468513
- Network
- In network
- Rendering NPI
- 4789972559
- Location
- Dallas, TX · TIN 25-8447887
- 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 | $148.00 | $91.76 | $20.00 | $71.76 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $211.00 | $130.82 | $0.00 | $130.82 | Paid |
| Totals | $359.00 | $222.58 | $20.00 | $202.58 | ||||||
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-545717
- 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-019497 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-25: CHOICE-PLUS-PPO (PPO), effective 2022-01-01. | |
| 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 Canyon Primary Care Associates (4536468513). | |
| 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: Canyon Primary Care Associates2026-02-25 13:54
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$359.00
Plan discount
$136.42
contracted rate
Plan paid
$202.58
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-2026-029299 | 2026-08-10 | Meadow Primary Care Associates | $43.00 | Approved |
| CLM-2026-001389 | 2026-04-04 | Sunrise Cardiovascular Associates | $334.00 | 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.