Professional claim · CMS-1500 · EDI 837P
CLM-2026-015302
Meadow Family Practice, Family Medicine. Service 2026-07-29 at office (POS 11). Received 2026-09-04.
Approved
Billed
$520.00
2 lines
Allowed
$322.40
contract rate applied
Plan pays
$292.40
approved
Member owes
$30.00
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
- Karen Foster
- Member ID
- UHC-09837-69
- Date of birth
- 1992-04-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421468
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1795
- Coverage period
- 2024-08-01 to present
- Deductible
- $378.52 of $3,500.0011%
- Out-of-pocket maximum
- $6,116.15 of $14,000.0044%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8614941473
- Network
- In network
- Rendering NPI
- 3550807291
- Location
- Atlanta, GA · TIN 64-8981661
- 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 | $281.00 | $174.22 | $30.00 | $144.22 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $239.00 | $148.18 | $0.00 | $148.18 | Paid |
| Totals | $520.00 | $322.40 | $30.00 | $292.40 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-869693
- 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-000741 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-29: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 37 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 (8614941473). | |
| 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 Practice2026-07-29 16:35
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
$520.00
Plan discount
$197.60
contracted rate
Plan paid
$292.40
You may owe
$30.00
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-2026-021328 | 2026-07-30 | Unity Dermatology Clinic | $781.00 | Needs review |
| CLM-2026-034114 | 2026-03-25 | Evergreen Internal Medicine Associates | $460.00 | Denied |
| CLM-2026-034113 | 2026-03-25 | Evergreen Internal Medicine Associates | $460.00 | 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.