Professional claim · CMS-1500 · EDI 837P
CLM-2026-012681
Pinecrest Medical Group, Internal Medicine. Service 2026-06-28 at office (POS 11). Received 2026-07-11.
Approved
Billed
$360.00
2 lines
Allowed
$223.20
contract rate applied
Plan pays
$183.20
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
- Walter Walter
- Member ID
- UHC-53046-17
- Date of birth
- 1972-11-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413047
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1780
- Coverage period
- 2021-05-01 to present
- Deductible
- $274.47 of $500.0055%
- Out-of-pocket maximum
- $842.92 of $2,000.0042%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 7579045775
- Location
- Nashville, TN · TIN 22-5526630
- Authorisation / referral
- none / REF736755
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $80.00 | $49.60 | $40.00 | $9.60 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $280.00 | $173.60 | $0.00 | $173.60 | Paid |
| Totals | $360.00 | $223.20 | $40.00 | $183.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-830262
- 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-013338 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-28: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| 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 Pinecrest Medical Group (3917182149). | |
| 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: Pinecrest Medical Group2026-06-28 17:53
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$360.00
Plan discount
$136.80
contracted rate
Plan paid
$183.20
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
No other claims.
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.