Professional claim · CMS-1500 · Paper
CLM-2026-019816
Cornerstone Family Practice, Family Medicine. Service 2026-03-17 at office (POS 11). Received 2026-03-21.
ApprovedOut of network
Billed
$256.00
1 line
Allowed
$115.20
contract rate applied
Plan pays
$95.20
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
- John Bowman
- Member ID
- UHC-78926-72
- Date of birth
- 1964-04-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418679
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4356
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,679.29 of $2,500.0067%
- Out-of-pocket maximum
- $2,289.07 of $5,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6150045915
- Network
- Out of network
- Rendering NPI
- 1842386744
- Location
- Minneapolis, MN · TIN 65-3309082
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $256.00 | $115.20 | $20.00 | $95.20 | Paid |
| Totals | $256.00 | $115.20 | $20.00 | $95.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-843215
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021234 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-17: OPTIONS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 4 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Cornerstone Family Practice2026-03-17 09:47
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$256.00
Plan discount
$140.80
out-of-network allowance
Plan paid
$95.20
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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.