Professional claim · CMS-1500 · EDI 837P
CLM-2026-017733
Riverside Digestive Health Center, Gastroenterology. Service 2025-12-20 at office (POS 11). Received 2026-01-11.
Approved
Billed
$268.00
1 line
Allowed
$166.16
contract rate applied
Plan pays
$116.16
approved
Member owes
$50.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Chapman Michael
- Member ID
- UHC-49233-42
- Date of birth
- 1938-11-13
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-404883
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0758
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,914.04 of $3,500.0055%
- Out-of-pocket maximum
- $3,198.86 of $7,000.0046%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 4313275453
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- none / REF848598
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $268.00 | $166.16 | $50.00 | $116.16 | Paid |
| Totals | $268.00 | $166.16 | $50.00 | $116.16 | ||||||
Diagnoses (ICD-10-CM)
- 1. R10.13 Epigastric painprincipal
Claim header
- Patient account
- PA-538956
- 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-003334 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-12-20: CORE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 22 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 Riverside Digestive Health Center (8834777772). | |
| 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: Riverside Digestive Health Center2025-12-20 12:01
Patient seen for epigastric pain.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$268.00
Plan discount
$101.84
contracted rate
Plan paid
$116.16
You may owe
$50.00
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
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.