Professional claim · CMS-1500 · EDI 837P
CLM-2026-017511
Mesa Medical Group, Family Medicine. Service 2026-05-08 at office (POS 11). Received 2026-05-29.
Approved
Billed
$223.00
2 lines
Allowed
$138.26
contract rate applied
Plan pays
$98.26
approved
Member owes
$40.00
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
- Adam Vega
- Member ID
- UHC-59055-13
- Date of birth
- 1992-02-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425772
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3911
- Coverage period
- 2024-03-01 to present
- Deductible
- $158.59 of $2,500.006%
- Out-of-pocket maximum
- $1,385.71 of $10,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3131727711
- Network
- In network
- Rendering NPI
- 5238121722
- Location
- Dallas, TX · TIN 70-1042424
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $195.00 | $120.90 | $40.00 | $80.90 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $28.00 | $17.36 | $0.00 | $17.36 | Paid |
| Totals | $223.00 | $138.26 | $40.00 | $98.26 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-263716
- 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-027921 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-08: OPTIONS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 21 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 Medical Group (3131727711). | |
| 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: Mesa Medical Group2026-05-08 13:11
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$223.00
Plan discount
$84.74
contracted rate
Plan paid
$98.26
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023742 | 2026-09-16 | Summit Regional Medical Center | $2,954.00 | Needs review |
| CLM-2026-005712 | 2026-08-06 | Desert Clinical Laboratories | $194.00 | Denied |
| CLM-2026-005711 | 2026-08-06 | Desert Clinical Laboratories | $194.00 | Approved |
| CLM-2026-000009 | 2026-07-27 | Lakeside Physical Therapy | $266.00 | Approved |
| CLM-2026-026554 | 2026-04-12 | Sunrise Digestive Health Center | $4,959.00 | Needs review |
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.