Professional claim · CMS-1500 · EDI 837P
CLM-2026-014110
Heritage Medical Group, Internal Medicine. Service 2026-06-13 at office (POS 11). Received 2026-06-30.
Approved
Billed
$369.00
2 lines
Allowed
$228.78
contract rate applied
Plan pays
$208.78
approved
Member owes
$20.00
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
- Gary Knight
- Member ID
- UHC-98151-65
- Date of birth
- 1974-09-02
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-424574
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5681
- Coverage period
- 2024-01-01 to present
- Deductible
- $118.65 of $500.0024%
- Out-of-pocket maximum
- $678.33 of $2,000.0034%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 3918447434
- Location
- Denver, CO · TIN 85-4450273
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $46.00 | $28.52 | $20.00 | $8.52 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1,2 | $323.00 | $200.26 | $0.00 | $200.26 | Paid |
| Totals | $369.00 | $228.78 | $20.00 | $208.78 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-996416
- 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-000224 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-13: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 17 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 Heritage Medical Group (9350331127). | |
| 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: Heritage Medical Group2026-06-13 12:42
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$369.00
Plan discount
$140.22
contracted rate
Plan paid
$208.78
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-2026-024628 | 2025-12-02 | Valley Family Practice | $40.00 | Needs review |
| CLM-2026-024627 | 2025-12-02 | Valley Family Practice | $40.00 | Approved |
| CLM-2026-001747 | 2025-12-12 | Pinecrest Regional Medical Center | $2,995.00 | 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.