Professional claim · CMS-1500 · EDI 837P
CLM-2026-013152
Meadow Medical Group, Family Medicine. Service 2026-03-31 at office (POS 11). Received 2026-04-07.
Approved
Billed
$65.00
2 lines
Allowed
$40.30
contract rate applied
Plan pays
$20.30
approved
Member owes
$20.00
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
- Joshua Armstrong
- Member ID
- UHC-90508-70
- Date of birth
- 1990-12-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-426225
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3572
- Coverage period
- 2024-01-01 to 2026-07-09
- Deductible
- $1,028.31 of $1,500.0069%
- Out-of-pocket maximum
- $2,264.84 of $6,000.0038%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7358617562
- Network
- In network
- Rendering NPI
- 4939148704
- Location
- Tempe, AZ · TIN 28-5097821
- 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 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $26.66 | $20.00 | $6.66 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $22.00 | $13.64 | $0.00 | $13.64 | Paid |
| Totals | $65.00 | $40.30 | $20.00 | $20.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-844080
- 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-008264 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-31: CHOICE-PLUS-PPO (PPO), effective 2024-01-01, terms 2026-07-09. | |
| Timely filing | Pass | Received 7 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 Meadow Medical Group (7358617562). | |
| 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: Meadow Medical Group2026-03-31 10:39
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$65.00
Plan discount
$24.70
contracted rate
Plan paid
$20.30
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-2026-020437 | 2026-07-24 | Canyon Primary Care Associates | $206.00 | Denied |
| CLM-2026-015056 | 2026-06-06 | Sunrise Cardiovascular Associates | $5,638.00 | Denied |
| CLM-2026-015055 | 2026-06-06 | Sunrise Cardiovascular Associates | $5,638.00 | Approved |
| CLM-2026-007327 | 2026-01-22 | Canyon Clinical Laboratories | $73.00 | Denied |
| CLM-2026-007326 | 2026-01-22 | Canyon Clinical Laboratories | $73.00 | 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.