Professional claim · CMS-1500 · EDI 837P
CLM-2026-012862
Riverside Primary Care Associates, Family Medicine. Service 2026-08-21 at office (POS 11). Received 2026-09-21.
Approved
Billed
$293.00
2 lines
Allowed
$181.66
contract rate applied
Plan pays
$156.66
approved
Member owes
$25.00
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
- Walter Harris
- Member ID
- UHC-38852-43
- Date of birth
- 1955-10-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401792
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2865
- Coverage period
- 2025-04-01 to present
- Deductible
- $840.43 of $1,500.0056%
- Out-of-pocket maximum
- $135.06 of $4,500.003%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 7169447837
- Location
- Phoenix, AZ · TIN 77-3257014
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $269.00 | $166.78 | $25.00 | $141.78 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $24.00 | $14.88 | $0.00 | $14.88 | Paid |
| Totals | $293.00 | $181.66 | $25.00 | $156.66 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-407098
- 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-013732 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-21: CHOICE-PLUS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 31 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 Riverside Primary Care Associates (6920830281). | |
| 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: Riverside Primary Care Associates2026-08-21 12:21
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$293.00
Plan discount
$111.34
contracted rate
Plan paid
$156.66
You may owe
$25.00
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-2026-020885 | 2026-03-21 | Desert Primary Care Associates | $579.00 | Approved |
| CLM-2026-018933 | 2026-02-28 | Heritage Digestive Health Center | $215.00 | Approved |
| CLM-2026-024617 | 2026-02-14 | Desert Reference Lab | $163.00 | 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.