Professional claim · CMS-1500 · EDI 837P
CLM-2026-014252
Riverside Digestive Health Center, Gastroenterology. Service 2026-01-19 at office (POS 11). Received 2026-02-26.
Approved
Billed
$240.00
1 line
Allowed
$148.80
contract rate applied
Plan pays
$88.80
approved
Member owes
$60.00
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
- Sharon Greene
- Member ID
- UHC-72907-79
- Date of birth
- 1982-12-09
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-418407
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5700
- Coverage period
- 2024-08-01 to present
- Deductible
- $58.34 of $500.0012%
- Out-of-pocket maximum
- $99.86 of $1,000.0010%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 2087545622
- Location
- Tempe, AZ · TIN 41-1081863
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $240.00 | $148.80 | $60.00 | $88.80 | Paid |
| Totals | $240.00 | $148.80 | $60.00 | $88.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
Claim header
- Patient account
- PA-302894
- 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-016102 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-19: N/A (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 38 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 Riverside Digestive Health Center (8834777772). | |
| 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: Riverside Digestive Health Center2026-01-19 17:16
Patient seen for epigastric pain.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$240.00
Plan discount
$91.20
contracted rate
Plan paid
$88.80
You may owe
$60.00
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-2026-020051 | 2026-03-29 | Canyon Reference Lab | $204.00 | 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.