Professional claim · CMS-1500 · Provider portal
CLM-2026-013339
Unity Primary Care Associates, Family Medicine. Service 2026-03-29 at office (POS 11). Received 2026-04-29.
ApprovedOut of network
Billed
$216.00
2 lines
Allowed
$97.20
contract rate applied
Plan pays
$57.20
approved
Member owes
$40.00
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
- Charles Hall
- Member ID
- UHC-31175-80
- Date of birth
- 1983-05-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400105
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8895
- Coverage period
- 2024-02-01 to 2026-06-05
- Deductible
- $2,117.59 of $2,500.0085%
- Out-of-pocket maximum
- $2,996.03 of $7,500.0040%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8247321622
- Network
- Out of network
- Rendering NPI
- 7940187637
- Location
- Tempe, AZ · TIN 17-5198361
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $194.00 | $87.30 | $40.00 | $47.30 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $9.90 | $0.00 | $9.90 | Paid |
| Totals | $216.00 | $97.20 | $40.00 | $57.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
Claim header
- Patient account
- PA-820859
- 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-007606 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-29: OPTIONS-PPO (PPO), effective 2024-02-01, terms 2026-06-05. | |
| 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 | 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: Unity Primary Care Associates2026-03-29 17:03
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$216.00
Plan discount
$118.80
out-of-network allowance
Plan paid
$57.20
You may owe
$40.00
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-2026-014056 | 2026-02-28 | Meadow Medical Group | $249.00 | Approved |
| CLM-2026-027586 | 2025-12-25 | Mesa Regional Medical Center | $1,524.00 | 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.