Professional claim · CMS-1500 · EDI 837P
CLM-2026-021015
Evergreen Family Practice, Family Medicine. Service 2026-06-07 at office (POS 11). Received 2026-07-03.
Approved
Billed
$440.00
2 lines
Allowed
$272.80
contract rate applied
Plan pays
$242.80
approved
Member owes
$30.00
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
- Russell Armstrong
- Member ID
- UHC-31168-68
- Date of birth
- 1968-04-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-412192
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group -
- Coverage period
- 2024-01-01 to present
- Deductible
- $153.44 of $2,500.006%
- Out-of-pocket maximum
- $2,386.15 of $10,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9703652849
- Network
- In network
- Rendering NPI
- 5928381669
- Location
- Miami, FL · TIN 83-6828766
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $188.00 | $116.56 | $30.00 | $86.56 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $252.00 | $156.24 | $0.00 | $156.24 | Paid |
| Totals | $440.00 | $272.80 | $30.00 | $242.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-132723
- 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-031315 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-07: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 26 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 Evergreen Family Practice (9703652849). | |
| 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: Evergreen Family Practice2026-06-07 17:15
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$440.00
Plan discount
$167.20
contracted rate
Plan paid
$242.80
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 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.