Professional claim · CMS-1500 · EDI 837P
CLM-2026-013264
Valley Primary Care Associates, Family Medicine. Service 2026-09-04 at office (POS 11). Received 2026-09-12.
ApprovedOut of network
Billed
$404.00
3 lines
Allowed
$181.80
contract rate applied
Plan pays
$171.45
approved
Member owes
$10.35
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
- Anthony Rios
- Member ID
- UHC-38512-88
- Date of birth
- 1984-09-02
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-406562
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2495
- Coverage period
- 2022-03-01 to present
- Deductible
- $488.97 of $1,000.0049%
- Out-of-pocket maximum
- $712.19 of $4,000.0018%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 1095352344
- Location
- Denver, CO · TIN 69-3521502
- 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 | $10.35 | $10.35 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $140.00 | $63.00 | $0.00 | $63.00 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $241.00 | $108.45 | $0.00 | $108.45 | Paid |
| Totals | $404.00 | $181.80 | $10.35 | $171.45 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-230971
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020010 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-04: MEDICARE-ADV-B (MA), effective 2022-03-01. | |
| Timely filing | Pass | Received 8 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Primary Care Associates2026-09-04 09:36
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$404.00
Plan discount
$222.20
out-of-network allowance
Plan paid
$171.45
You may owe
$10.35
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008761 | 2026-09-28 | Harbor Medical Group | $683.00 | Approved |
| CLM-2026-027829 | 2026-07-31 | Sunrise Digestive Health Center | $1,583.00 | Approved |
| CLM-2026-028443 | 2026-07-10 | Summit Diagnostic Imaging | $2,033.00 | Needs review |
| CLM-2026-012529 | 2026-06-05 | Summit Internal Medicine Associates | $434.00 | 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.