Professional claim · CMS-1500 · EDI 837P
CLM-2026-017949
Mesa Family Practice, Family Medicine. Service 2025-12-13 at office (POS 11). Received 2026-01-08.
Approved
Billed
$565.00
3 lines
Allowed
$350.30
contract rate applied
Plan pays
$320.30
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Douglas Garza
- Member ID
- UHC-82645-48
- Date of birth
- 1946-09-15
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-406600
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4585
- Coverage period
- 2021-01-01 to 2026-08-06
- Deductible
- $79.15 of $3,500.002%
- Out-of-pocket maximum
- $937.92 of $10,500.009%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7916099477
- Network
- In network
- Rendering NPI
- 9975349777
- Location
- Miami, FL · TIN 48-0020072
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $265.00 | $164.30 | $30.00 | $134.30 | Paid |
| 2 | 90471 | Immunization administration | 25 | 1 | 1 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $258.00 | $159.96 | $0.00 | $159.96 | Paid |
| Totals | $565.00 | $350.30 | $30.00 | $320.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-175094
- 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-002425 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-13: MEDICARE-ADV-B (MA), effective 2021-01-01, terms 2026-08-06. | |
| Timely filing | Pass | Received 26 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 Family Practice (7916099477). | |
| 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 Family Practice2025-12-13 17:47
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$565.00
Plan discount
$214.70
contracted rate
Plan paid
$320.30
You may owe
$30.00
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-2026-026596 | 2026-01-30 | Mesa Internal Medicine Associates | $84.00 | Denied |
| CLM-2026-027853 | 2026-03-08 | Northgate Primary Care Associates | $250.00 | Denied |
| CLM-2026-027852 | 2026-03-08 | Northgate Primary Care Associates | $250.00 | 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.