Professional claim · CMS-1500 · EDI 837P
CLM-2026-013133
Valley Medical Group, Internal Medicine. Service 2026-08-27 at office (POS 11). Received 2026-10-11.
Approved
Billed
$63.00
1 line
Allowed
$39.06
contract rate applied
Plan pays
$19.06
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Olivia Gonzales
- Member ID
- UHC-00411-18
- Date of birth
- 1943-12-08
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-421623
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4122
- Coverage period
- 2025-12-01 to present
- Deductible
- $753.30 of $1,500.0050%
- Out-of-pocket maximum
- $20.03 of $3,000.001%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 5528319606
- Location
- Nashville, TN · TIN 16-4753822
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $63.00 | $39.06 | $20.00 | $19.06 | Paid |
| Totals | $63.00 | $39.06 | $20.00 | $19.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-941469
- 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-002960 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-27: SELECT-EPO (EPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 45 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 Valley Medical Group (1946396904). | |
| 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: Valley Medical Group2026-08-27 14:06
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$63.00
Plan discount
$23.94
contracted rate
Plan paid
$19.06
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-2026-018125 | 2026-08-07 | Canyon Diagnostic Imaging | $3,997.00 | Approved |
| CLM-2026-015450 | 2026-08-22 | Riverside Bone and Joint Center | $8,605.00 | Denied |
| CLM-2026-022299 | 2026-06-30 | Sunrise Dermatology Clinic | $217.00 | Needs review |
| CLM-2026-024851 | 2026-03-15 | Mesa Physical Therapy | $248.00 | 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.