Claims workbench/CLM-2026-015643
Professional claim · CMS-1500 · EDI 837P

CLM-2026-015643

Unity Medical Group, Internal Medicine. Service 2026-08-11 at office (POS 11). Received 2026-09-15.

Approved
Billed
$299.00
1 line
Allowed
$185.38
contract rate applied
Plan pays
$160.38
approved
Member owes
$25.00
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
Ronald Lawson
Member ID
UHC-93268-33
Date of birth
1991-08-03
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-410924
Relationship
Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group -
Coverage period
2021-12-01 to present
Deductible
$372.50 of $1,000.0037%
Out-of-pocket maximum
$563.67 of $2,000.0028%
Copays
office $25.00, specialist $50.00, emergency $150.00
Physical therapy visits
2 of 20 used

Provider

Billing and rendering

Billing provider
Unity Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
1276733437
Network
In network
Rendering NPI
6650459178
Location
Dallas, TX · TIN 20-2485956
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$299.00$185.38$25.00$160.38Paid
Totals$299.00$185.38$25.00$160.38
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
  • 3. I48.91 Unspecified atrial fibrillation
Claim header
Patient account
PA-840477
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-007153 (verified, link confidence 0.99).
EligibilityPassActive on 2026-08-11: SELECT-EPO (EPO), effective 2021-12-01.
Timely filingPassReceived 35 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Medical Group (1276733437).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Unity Medical Group2026-08-11 09:49

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$299.00
Plan discount
$113.62
contracted rate
Plan paid
$160.38
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

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.

Review queueMember identity