Professional claim · CMS-1500 · EDI 837P
CLM-2026-018056
Meadow Family Practice, Family Medicine. Service 2026-08-10 at office (POS 11). Received 2026-08-18.
Approved
Billed
$627.00
3 lines
Allowed
$388.74
contract rate applied
Plan pays
$368.74
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Julie Parker
- Member ID
- UHC-44097-04
- Date of birth
- 1969-01-20
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413505
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5174
- Coverage period
- 2022-10-01 to present
- Deductible
- $436.44 of $500.0087%
- Out-of-pocket maximum
- $178.37 of $2,000.009%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5067162870
- Network
- In network
- Rendering NPI
- 7113247598
- Location
- Nashville, TN · TIN 66-6363148
- 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 | $156.00 | $96.72 | $20.00 | $76.72 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $181.00 | $112.22 | $0.00 | $112.22 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $290.00 | $179.80 | $0.00 | $179.80 | Paid |
| Totals | $627.00 | $388.74 | $20.00 | $368.74 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-179407
- 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-003884 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-10: MEDICARE-ADV-A (MA), effective 2022-10-01. | |
| Timely filing | Pass | Received 8 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 Meadow Family Practice (5067162870). | |
| 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: Meadow Family Practice2026-08-10 09:44
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$627.00
Plan discount
$238.26
contracted rate
Plan paid
$368.74
You may owe
$20.00
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.