Professional claim · CMS-1500 · EDI 837P
CLM-2026-019168
Valley Family Practice, Family Medicine. Service 2026-01-08 at office (POS 11). Received 2026-02-14.
Approved
Billed
$803.00
3 lines
Allowed
$497.86
contract rate applied
Plan pays
$472.86
approved
Member owes
$25.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Elizabeth Wilson
- Member ID
- UHC-61515-34
- Date of birth
- 1957-02-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400694
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4816
- Coverage period
- 2021-11-01 to 2026-04-08
- Deductible
- $423.07 of $1,500.0028%
- Out-of-pocket maximum
- $1,991.28 of $6,000.0033%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 2224730681
- Location
- Houston, TX · TIN 34-3279519
- 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 | $309.00 | $191.58 | $25.00 | $166.58 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $203.00 | $125.86 | $0.00 | $125.86 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $291.00 | $180.42 | $0.00 | $180.42 | Paid |
| Totals | $803.00 | $497.86 | $25.00 | $472.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-947517
- 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-005588 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-08: CHOICE-PLUS-PPO (PPO), effective 2021-11-01, terms 2026-04-08. | |
| Timely filing | Pass | Received 37 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 Valley Family Practice (3411841638). | |
| 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: Valley Family Practice2026-01-08 18:27
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
$803.00
Plan discount
$305.14
contracted rate
Plan paid
$472.86
You may owe
$25.00
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
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.