Professional claim · CMS-1500 · EDI 837P
CLM-2026-012121
Northgate Heart Institute, Cardiology. Service 2026-07-25 at office (POS 11). Received 2026-08-12.
Approved
Billed
$554.00
2 lines
Allowed
$343.48
contract rate applied
Plan pays
$293.48
approved
Member owes
$50.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Brenda Sullivan
- Member ID
- UHC-04246-79
- Date of birth
- 1992-01-01
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-414670
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2021-12-01 to present
- Deductible
- $2,003.15 of $2,500.0080%
- Out-of-pocket maximum
- $1,739.15 of $5,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 4082625359
- Location
- Los Angeles, CA · TIN 48-8536899
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $325.00 | $201.50 | $50.00 | $151.50 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $229.00 | $141.98 | $0.00 | $141.98 | Paid |
| Totals | $554.00 | $343.48 | $50.00 | $293.48 | ||||||
Diagnoses (ICD-10-CM)
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-494872
- 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-017299 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-25: N/A (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 18 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 Northgate Heart Institute (1929886434). | |
| 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: Northgate Heart Institute2026-07-25 14:21
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$554.00
Plan discount
$210.52
contracted rate
Plan paid
$293.48
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-2026-019645 | 2026-02-02 | Meadow Family Practice | $476.00 | 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.