Professional claim · CMS-1500 · EDI 837P
CLM-2026-015370
Mesa Medical Group, Family Medicine. Service 2026-07-05 at office (POS 11). Received 2026-07-23.
Approved
Billed
$432.00
3 lines
Allowed
$267.84
contract rate applied
Plan pays
$247.84
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
- Aaron Rojas
- Member ID
- UHC-11544-93
- Date of birth
- 1980-11-08
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-413153
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2167
- Coverage period
- 2025-08-01 to present
- Deductible
- $495.62 of $2,500.0020%
- Out-of-pocket maximum
- $2,443.55 of $5,000.0049%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 5760508650
- Location
- Los Angeles, CA · TIN 30-7296562
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $190.00 | $117.80 | $20.00 | $97.80 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $24.00 | $14.88 | $0.00 | $14.88 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $218.00 | $135.16 | $0.00 | $135.16 | Paid |
| Totals | $432.00 | $267.84 | $20.00 | $247.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-251758
- 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-008337 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-05: NULL (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 18 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 Mesa Medical Group (7662849547). | |
| 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: Mesa Medical Group2026-07-05 18:34
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$432.00
Plan discount
$164.16
contracted rate
Plan paid
$247.84
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-2026-015371 | 2026-07-05 | Mesa Medical Group | $432.00 | Needs review |
| CLM-2026-018804 | 2026-05-31 | Meadow Dermatology Clinic | $201.00 | 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.