Professional claim · CMS-1500 · EDI 837P
CLM-2026-019890
Unity Medical Group, Internal Medicine. Service 2026-02-22 at office (POS 11). Received 2026-03-06.
Approved
Billed
$442.00
2 lines
Allowed
$274.04
contract rate applied
Plan pays
$244.04
approved
Member owes
$30.00
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
- Lucia Lynch
- Member ID
- UHC-33985-39
- Date of birth
- 1968-04-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406358
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8977
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,709.22 of $2,500.0068%
- Out-of-pocket maximum
- $45.42 of $10,000.000%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 7465771997
- Location
- Mesa, AZ · TIN 43-9161942
- 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 | $380.00 | $235.60 | $30.00 | $205.60 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1,2 | $62.00 | $38.44 | $0.00 | $38.44 | Paid |
| Totals | $442.00 | $274.04 | $30.00 | $244.04 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-196579
- 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-017911 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-22: NULL (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 12 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 Unity Medical Group (1355996814). | |
| 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: Unity Medical Group2026-02-22 12:49
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$442.00
Plan discount
$167.96
contracted rate
Plan paid
$244.04
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-2026-013913 | 2026-09-07 | Meadow Heart Institute | $641.00 | Approved |
| CLM-2026-013567 | 2026-06-11 | Pinecrest Regional Medical Center | $2,919.00 | Approved |
| CLM-2026-019891 | 2026-02-22 | Unity Medical Group | $442.00 | Denied |
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.