Professional claim · CMS-1500 · EDI 837P
CLM-2026-017869
Unity Medical Group, Family Medicine. Service 2026-07-14 at office (POS 11). Received 2026-08-23.
Approved
Billed
$458.00
3 lines
Allowed
$283.96
contract rate applied
Plan pays
$271.56
approved
Member owes
$12.40
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
- Gabriel Munoz
- Member ID
- UHC-75314-01
- Date of birth
- 1938-08-21
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-409172
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1393
- Coverage period
- 2023-11-01 to present
- Deductible
- $734.63 of $1,000.0073%
- Out-of-pocket maximum
- $362.02 of $2,000.0018%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6749849405
- Network
- In network
- Rendering NPI
- 3102709938
- Location
- Houston, TX · TIN 69-3600999
- 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 | 36415 | Venipuncture | — | 1 | 1 | $20.00 | $12.40 | $12.40 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $197.00 | $122.14 | $0.00 | $122.14 | Paid |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $241.00 | $149.42 | $0.00 | $149.42 | Paid |
| Totals | $458.00 | $283.96 | $12.40 | $271.56 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-150518
- 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-017604 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-14: CHOICE-PLUS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 40 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 Unity Medical Group (6749849405). | |
| 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: Unity Medical Group2026-07-14 14:40
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$458.00
Plan discount
$174.04
contracted rate
Plan paid
$271.56
You may owe
$12.40
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022878 | 2026-08-17 | Evergreen Diagnostic Imaging | $1,724.00 | Approved |
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.