Professional claim · CMS-1500 · EDI 837P
CLM-2026-020776
Northgate Heart Institute, Cardiology. Service 2026-01-14 at office (POS 11). Received 2026-02-13.
Approved
Billed
$577.00
2 lines
Allowed
$357.74
contract rate applied
Plan pays
$282.74
approved
Member owes
$75.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Juan Lopez
- Member ID
- UHC-13601-93
- Date of birth
- 1968-10-05
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-414751
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7876
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,111.34 of $1,500.0074%
- Out-of-pocket maximum
- $1,439.51 of $4,500.0032%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 7288546659
- Location
- San Diego, CA · TIN 46-7688844
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $349.00 | $216.38 | $75.00 | $141.38 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $228.00 | $141.36 | $0.00 | $141.36 | Paid |
| Totals | $577.00 | $357.74 | $75.00 | $282.74 | ||||||
Diagnoses (ICD-10-CM)
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
Claim header
- Patient account
- PA-461871
- 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-012669 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-14: MEDICARE-ADV-A (MA), effective 2025-10-01. | |
| Timely filing | Pass | Received 30 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 Northgate Heart Institute (5192135197). | |
| 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: Northgate Heart Institute2026-01-14 09:08
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$577.00
Plan discount
$219.26
contracted rate
Plan paid
$282.74
You may owe
$75.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008278 | 2026-03-03 | Evergreen Family Practice | $375.00 | 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.