Professional claim · CMS-1500 · EDI 837P
CLM-2026-017906
Riverside Primary Care Associates, Family Medicine. Service 2026-07-21 at office (POS 11). Received 2026-08-10.
Approved
Billed
$460.00
3 lines
Allowed
$285.20
contract rate applied
Plan pays
$245.20
approved
Member owes
$40.00
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
- Theresa Wells
- Member ID
- UHC-58831-89
- Date of birth
- 1947-06-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416005
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0337
- Coverage period
- 2023-04-01 to present
- Deductible
- $86.12 of $1,000.009%
- Out-of-pocket maximum
- $761.53 of $2,000.0038%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6269804525
- Network
- In network
- Rendering NPI
- 5619940666
- Location
- Los Angeles, CA · TIN 64-8796526
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $146.00 | $90.52 | $40.00 | $50.52 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $44.00 | $27.28 | $0.00 | $27.28 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $270.00 | $167.40 | $0.00 | $167.40 | Paid |
| Totals | $460.00 | $285.20 | $40.00 | $245.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-594256
- 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-041130 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-21: CHOICE-PLUS-PPO (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 20 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 Primary Care Associates (6269804525). | |
| 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 Primary Care Associates2026-07-21 17:31
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
$460.00
Plan discount
$174.80
contracted rate
Plan paid
$245.20
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
- AI recommendation recordedcli_adjudicator2026-10-21 13:39 · 174936ab
- AI recommendation validatedClaims rules engine2026-10-21 13:39 · dbcd1be3
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.