Professional claim · CMS-1500 · EDI 837P
CLM-2026-014504
Meadow GI Associates, Gastroenterology. Service 2026-03-08 at office (POS 11). Received 2026-03-12.
ApprovedOut of network
Billed
$245.00
1 line
Allowed
$110.25
contract rate applied
Plan pays
$70.25
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Nancy Myers
- Member ID
- UHC-26902-60
- Date of birth
- 1999-06-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427753
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3212
- Coverage period
- 2023-07-01 to present
- Deductible
- $510.16 of $1,500.0034%
- Out-of-pocket maximum
- $1,264.57 of $6,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 2807573961
- Location
- Los Angeles, CA · TIN 16-0400328
- 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 | $245.00 | $110.25 | $40.00 | $70.25 | Paid |
| Totals | $245.00 | $110.25 | $40.00 | $70.25 | ||||||
Diagnoses (ICD-10-CM)
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
Claim header
- Patient account
- PA-771098
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019198 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-08: MEDICARE-ADV-A (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 4 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow GI Associates2026-03-08 14:37
Patient seen for epigastric pain.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$245.00
Plan discount
$134.75
out-of-network allowance
Plan paid
$70.25
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
No other claims.
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.