Professional claim · CMS-1500 · EDI 837P
CLM-2026-020593
Harbor Family Practice, Family Medicine. Service 2026-04-28 at office (POS 11). Received 2026-05-16.
Approved
Billed
$214.00
2 lines
Allowed
$132.68
contract rate applied
Plan pays
$125.24
approved
Member owes
$7.44
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Ashley Schmidt
- Member ID
- UHC-48601-56
- Date of birth
- 1947-03-01
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-412889
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2023-11-01 to 2026-08-13
- Deductible
- $264.62 of $500.0053%
- Out-of-pocket maximum
- $143.97 of $2,000.007%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3348247230
- Network
- In network
- Rendering NPI
- 6626512522
- Location
- Austin, TX · TIN 89-3690484
- 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 | 36415 | Venipuncture | — | 1 | 1 | $12.00 | $7.44 | $7.44 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $202.00 | $125.24 | $0.00 | $125.24 | Paid |
| Totals | $214.00 | $132.68 | $7.44 | $125.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-437291
- 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-021782 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-28: MEDICARE-ADV-B (MA), effective 2023-11-01, terms 2026-08-13. | |
| Timely filing | Pass | Received 18 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 Harbor Family Practice (3348247230). | |
| 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: Harbor Family Practice2026-04-28 18:43
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
$214.00
Plan discount
$81.32
contracted rate
Plan paid
$125.24
You may owe
$7.44
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.