Professional claim · CMS-1500 · EDI 837P
CLM-2026-012163
Desert Internal Medicine Associates, Internal Medicine. Service 2026-08-30 at office (POS 11). Received 2026-09-22.
Approved
Billed
$149.00
2 lines
Allowed
$92.38
contract rate applied
Plan pays
$52.38
approved
Member owes
$40.00
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
- Nancy George
- Member ID
- UHC-95306-31
- Date of birth
- 1979-06-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420241
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5615
- Coverage period
- 2022-06-01 to present
- Deductible
- $12.71 of $1,500.001%
- Out-of-pocket maximum
- $417.43 of $3,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 9473557509
- Location
- Mesa, AZ · TIN 70-7613029
- Authorisation / referral
- none / REF296659
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $87.00 | $53.94 | $40.00 | $13.94 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1 | $62.00 | $38.44 | $0.00 | $38.44 | Paid |
| Totals | $149.00 | $92.38 | $40.00 | $52.38 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
Claim header
- Patient account
- PA-398919
- 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-014018 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-30: CORE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 23 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 Desert Internal Medicine Associates (6778439607). | |
| 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: Desert Internal Medicine Associates2026-08-30 09:18
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$149.00
Plan discount
$56.62
contracted rate
Plan paid
$52.38
You may owe
$40.00
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-2026-028706 | 2026-07-09 | Valley Imaging Center | $1,800.00 | Needs review |
| CLM-2026-028705 | 2026-07-09 | Valley Imaging Center | $1,800.00 | Approved |
| CLM-2026-015563 | 2026-05-22 | Desert Imaging Center | $2,416.00 | 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.