Professional claim · CMS-1500 · EDI 837P
CLM-2026-020948
Meadow Primary Care Associates, Family Medicine. Service 2026-05-13 at office (POS 11). Received 2026-06-23.
Approved
Billed
$431.00
3 lines
Allowed
$267.22
contract rate applied
Plan pays
$247.22
approved
Member owes
$20.00
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
- Jack Espinoza
- Member ID
- UHC-29115-37
- Date of birth
- 2001-01-19
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-428893
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4527
- Coverage period
- 2025-10-01 to 2026-06-09
- Deductible
- $286.96 of $500.0057%
- Out-of-pocket maximum
- $385.30 of $2,000.0019%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 9704343703
- Network
- In network
- Rendering NPI
- 2137285500
- Location
- Tampa, FL · TIN 74-5049309
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $219.00 | $135.78 | $20.00 | $115.78 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $199.00 | $123.38 | $0.00 | $123.38 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $13.00 | $8.06 | $0.00 | $8.06 | Paid |
| Totals | $431.00 | $267.22 | $20.00 | $247.22 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-464821
- 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-001204 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-13: SELECT-EPO (EPO), effective 2025-10-01, terms 2026-06-09. | |
| Timely filing | Pass | Received 41 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 Meadow Primary Care Associates (9704343703). | |
| 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: Meadow Primary Care Associates2026-05-13 14:15
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$431.00
Plan discount
$163.78
contracted rate
Plan paid
$247.22
You may owe
$20.00
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-2026-027451 | 2026-08-24 | Pinecrest Primary Care Associates | $25.00 | Denied |
| CLM-2026-032484 | 2026-06-05 | Summit Reference Lab | $79.00 | Denied |
| CLM-2026-013504 | 2026-01-07 | Sunrise Behavioral Health | $326.00 | 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.