Professional claim · CMS-1500 · EDI 837P
CLM-2026-017039
Sunrise Medical Group, Internal Medicine. Service 2025-12-30 at office (POS 11). Received 2026-02-05.
Approved
Billed
$695.00
2 lines
Allowed
$430.90
contract rate applied
Plan pays
$390.90
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Melissa Vasquez
- Member ID
- UHC-30778-66
- Date of birth
- 1998-05-26
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401626
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8553
- Coverage period
- 2023-08-01 to present
- Deductible
- $871.18 of $1,500.0058%
- Out-of-pocket maximum
- $1,244.36 of $6,000.0021%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4023193814
- Network
- In network
- Rendering NPI
- 7947320447
- Location
- Austin, TX · TIN 44-7321338
- Authorisation / referral
- none / REF317495
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $408.00 | $252.96 | $40.00 | $212.96 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $287.00 | $177.94 | $0.00 | $177.94 | Paid |
| Totals | $695.00 | $430.90 | $40.00 | $390.90 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
Claim header
- Patient account
- PA-907364
- 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-010672 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-30: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 37 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 Sunrise Medical Group (4023193814). | |
| 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: Sunrise Medical Group2025-12-30 12:26
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
$695.00
Plan discount
$264.10
contracted rate
Plan paid
$390.90
You may owe
$40.00
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
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.