Professional claim · CMS-1500 · Provider portal
CLM-2026-016631
Mesa Diabetes Center, Endocrinology. Service 2026-09-20 at office (POS 11). Received 2026-10-04.
Approved
Billed
$794.00
3 lines
Allowed
$492.28
contract rate applied
Plan pays
$448.26
approved
Member owes
$44.02
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
- Samuel Salazar
- Member ID
- UHC-29299-52
- Date of birth
- 1980-09-13
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-419062
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3938
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,148.22 of $3,500.0033%
- Out-of-pocket maximum
- $4,779.09 of $10,500.0046%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 1694828611
- Location
- Scottsdale, AZ · TIN 19-2073831
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $71.00 | $44.02 | $44.02 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $305.00 | $189.10 | $0.00 | $189.10 | Paid |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $418.00 | $259.16 | $0.00 | $259.16 | Paid |
| Totals | $794.00 | $492.28 | $44.02 | $448.26 | ||||||
Diagnoses (ICD-10-CM)
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-635472
- 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-008869 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-20: SELECT-EPO (EPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 14 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 Diabetes Center (3634244123). | |
| 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: Mesa Diabetes Center2026-09-20 16:03
Patient seen for hypothyroidism, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$794.00
Plan discount
$301.72
contracted rate
Plan paid
$448.26
You may owe
$44.02
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
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.