Professional claim · CMS-1500 · EDI 837P
CLM-2026-013249
Mesa Family Practice, Family Medicine. Service 2026-02-12 at office (POS 11). Received 2026-02-22.
Approved
Billed
$168.00
2 lines
Allowed
$104.16
contract rate applied
Plan pays
$89.90
approved
Member owes
$14.26
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ryan Diaz
- Member ID
- UHC-85118-52
- Date of birth
- 1991-04-01
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-408434
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1969
- Coverage period
- 2023-01-01 to present
- Deductible
- $455.67 of $3,500.0013%
- Out-of-pocket maximum
- $3,161.43 of $10,500.0030%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3505890145
- Network
- In network
- Rendering NPI
- 7807695581
- Location
- Atlanta, GA · TIN 15-9233501
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | $14.26 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $145.00 | $89.90 | $0.00 | $89.90 | Paid |
| Totals | $168.00 | $104.16 | $14.26 | $89.90 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-700771
- 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-014971 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-12: SELECT-EPO (EPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 10 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 Mesa Family Practice (3505890145). | |
| 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: Mesa Family Practice2026-02-12 17:45
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
$168.00
Plan discount
$63.84
contracted rate
Plan paid
$89.90
You may owe
$14.26
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-2026-025347 | 2026-07-19 | Lakeside Dermatology Clinic | $386.00 | Approved |
| CLM-2026-009976 | 2026-05-03 | Valley Medical Group | $247.00 | Denied |
| CLM-2026-009975 | 2026-05-03 | Valley Medical Group | $247.00 | Approved |
| CLM-2026-010964 | 2026-04-17 | Desert Cardiovascular Associates | $225.00 | 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.