Professional claim · CMS-1500 · EDI 837P
CLM-2026-016020
Desert Medical Group, Internal Medicine. Service 2026-08-15 at office (POS 11). Received 2026-09-23.
Approved
Billed
$274.00
2 lines
Allowed
$169.88
contract rate applied
Plan pays
$139.88
approved
Member owes
$30.00
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
- Kenneth James
- Member ID
- UHC-79845-73
- Date of birth
- 1941-08-01
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-423172
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3048
- Coverage period
- 2025-04-01 to present
- Deductible
- $350.15 of $500.0070%
- Out-of-pocket maximum
- $773.78 of $2,000.0039%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5303428622
- Network
- In network
- Rendering NPI
- 2350231637
- Location
- Atlanta, GA · TIN 67-2719316
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $72.00 | $44.64 | $30.00 | $14.64 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $202.00 | $125.24 | $0.00 | $125.24 | Paid |
| Totals | $274.00 | $169.88 | $30.00 | $139.88 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-698049
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025861 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-15: NAVIGATE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 39 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 Desert Medical Group (5303428622). | |
| 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: Desert Medical Group2026-08-15 10:11
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$274.00
Plan discount
$104.12
contracted rate
Plan paid
$139.88
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022707 | 2026-04-06 | Heritage Imaging Center | $2,030.00 | 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.