Professional claim · CMS-1500 · Provider portal
CLM-2026-013552
Meadow Family Practice, Family Medicine. Service 2026-09-02 at office (POS 11). Received 2026-09-22.
Approved
Billed
$349.00
2 lines
Allowed
$216.38
contract rate applied
Plan pays
$204.60
approved
Member owes
$11.78
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
- Omar Weaver
- Member ID
- UHC-71491-85
- Date of birth
- 2002-02-28
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-426342
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1335
- Coverage period
- 2022-02-01 to present
- Deductible
- $35.76 of $2,500.001%
- Out-of-pocket maximum
- $4,627.53 of $10,000.0046%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5067162870
- Network
- In network
- Rendering NPI
- 9675665928
- Location
- Nashville, TN · TIN 66-6363148
- 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 | $19.00 | $11.78 | $11.78 | $0.00 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $330.00 | $204.60 | $0.00 | $204.60 | Paid |
| Totals | $349.00 | $216.38 | $11.78 | $204.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-883960
- 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-004693 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-02: NAVIGATE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 20 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 Family Practice (5067162870). | |
| 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 Family Practice2026-09-02 13:07
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$349.00
Plan discount
$132.62
contracted rate
Plan paid
$204.60
You may owe
$11.78
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-2026-011167 | 2026-09-05 | Pinecrest Bone and Joint Center | $316.00 | Approved |
| CLM-2026-012943 | 2026-07-22 | Unity Medical Group | $269.00 | Approved |
| CLM-2026-031337 | 2025-12-10 | Riverside GI Associates | $1,541.00 | 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.