Professional claim · CMS-1500 · EDI 837P
CLM-2026-020797
Sunrise Medical Group, Family Medicine. Service 2026-05-21 at office (POS 11). Received 2026-07-02.
Approved
Billed
$287.00
1 line
Allowed
$177.94
contract rate applied
Plan pays
$137.94
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jeremy Reyes
- Member ID
- UHC-87372-54
- Date of birth
- 1973-02-03
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-407928
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2281
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,948.38 of $2,500.0078%
- Out-of-pocket maximum
- $1,869.80 of $7,500.0025%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7750705916
- Network
- In network
- Rendering NPI
- 9264968691
- Location
- Tampa, FL · TIN 44-4657025
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $287.00 | $177.94 | $40.00 | $137.94 | Paid |
| Totals | $287.00 | $177.94 | $40.00 | $137.94 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-149214
- 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-003804 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-21: MEDICARE-ADV-A (MA), effective 2025-03-01. | |
| Timely filing | Pass | Received 42 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 Sunrise Medical Group (7750705916). | |
| 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: Sunrise Medical Group2026-05-21 09:06
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$287.00
Plan discount
$109.06
contracted rate
Plan paid
$137.94
You may owe
$40.00
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-2026-032883 | 2026-02-23 | Desert Internal Medicine Associates | $242.00 | Approved |
| CLM-2026-016198 | 2026-01-29 | Riverside Regional Medical Center | $1,476.00 | Approved |
| CLM-2026-000822 | 2026-01-03 | Heritage Imaging Center | $2,311.00 | Needs review |
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.