Professional claim · CMS-1500 · EDI 837P
CLM-2026-018931
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-07-22 at office (POS 11). Received 2026-08-12.
Approved
Billed
$455.00
2 lines
Allowed
$282.10
contract rate applied
Plan pays
$242.10
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Stephen McCoy
- Member ID
- UHC-00347-08
- Date of birth
- 1976-03-10
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-409984
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3079
- Coverage period
- 2022-09-01 to present
- Deductible
- $1,902.58 of $2,500.0076%
- Out-of-pocket maximum
- $2,716.40 of $7,500.0036%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 6070847325
- Location
- Houston, TX · TIN 60-7207391
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $384.00 | $238.08 | $40.00 | $198.08 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1,2 | $71.00 | $44.02 | $0.00 | $44.02 | Paid |
| Totals | $455.00 | $282.10 | $40.00 | $242.10 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-329419
- 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-005747 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-22: OPTIONS-PPO (PPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 21 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 Internal Medicine Associates (1153640218). | |
| 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 Internal Medicine Associates2026-07-22 10:55
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$455.00
Plan discount
$172.90
contracted rate
Plan paid
$242.10
You may owe
$40.00
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-2026-022439 | 2026-08-09 | Unity Cardiovascular Associates | $1,110.00 | Approved |
| CLM-2026-023181 | 2025-12-06 | Evergreen Medical Group | $75.00 | Denied |
| CLM-2026-023180 | 2025-12-06 | Evergreen Medical Group | $75.00 | 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.