Professional claim · CMS-1500 · EDI 837P
CLM-2026-016114
Heritage Family Practice, Family Medicine. Service 2026-01-25 at office (POS 11). Received 2026-01-31.
Approved
Billed
$203.00
2 lines
Allowed
$125.86
contract rate applied
Plan pays
$101.06
approved
Member owes
$24.80
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
- Natalie Hoffman
- Member ID
- UHC-91848-90
- Date of birth
- 1973-05-14
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-418637
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4643
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,057.09 of $1,500.0070%
- Out-of-pocket maximum
- $811.55 of $4,500.0018%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 5205737427
- Location
- Scottsdale, AZ · TIN 98-1410500
- 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 | 90471 | Immunization administration | — | 1 | 1 | $40.00 | $24.80 | $24.80 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $163.00 | $101.06 | $0.00 | $101.06 | Paid |
| Totals | $203.00 | $125.86 | $24.80 | $101.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-726865
- 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-009080 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-25: CHOICE-PLUS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 6 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 Heritage Family Practice (3586851693). | |
| 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: Heritage Family Practice2026-01-25 14:09
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$203.00
Plan discount
$77.14
contracted rate
Plan paid
$101.06
You may owe
$24.80
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-2026-029462 | 2026-01-14 | Harbor Medical Group | $337.00 | Needs review |
| CLM-2026-029461 | 2026-01-14 | Desert Internal Medicine Associates | $337.00 | Approved |
| CLM-2026-016115 | 2026-01-25 | Heritage Family Practice | $203.00 | Denied |
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.