Professional claim · CMS-1500 · EDI 837P
CLM-2026-020624
Heritage Medical Group, Internal Medicine. Service 2026-02-04 at office (POS 11). Received 2026-03-01.
Approved
Billed
$90.00
1 line
Allowed
$55.80
contract rate applied
Plan pays
$25.80
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Carlos Lawrence
- Member ID
- UHC-66269-80
- Date of birth
- 1957-09-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402080
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5005
- Coverage period
- 2024-09-01 to present
- Deductible
- $949.26 of $1,500.0063%
- Out-of-pocket maximum
- $794.16 of $3,000.0026%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 1840904555
- Location
- Austin, TX · TIN 10-1675475
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $90.00 | $55.80 | $30.00 | $25.80 | Paid |
| Totals | $90.00 | $55.80 | $30.00 | $25.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-370341
- 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-016751 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-04: NULL (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 25 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 Heritage Medical Group (5190573977). | |
| 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: Heritage Medical Group2026-02-04 18:50
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$90.00
Plan discount
$34.20
contracted rate
Plan paid
$25.80
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-2026-033210 | 2026-07-21 | Meadow GI Associates | $1,845.00 | Approved |
| CLM-2026-017425 | 2026-02-01 | Unity Bone and Joint Center | $234.00 | 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.