Professional claim · CMS-1500 · EDI 837P
CLM-2026-021978
Mesa Family Practice, Family Medicine. Service 2026-01-09 at office (POS 11). Received 2026-01-14.
Approved
Billed
$496.00
3 lines
Allowed
$307.52
contract rate applied
Plan pays
$287.52
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Sandra Patel
- Member ID
- UHC-95354-02
- Date of birth
- 1950-08-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431116
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2650
- Coverage period
- 2022-07-01 to present
- Deductible
- $810.55 of $3,500.0023%
- Out-of-pocket maximum
- $8.00 of $10,500.000%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 1025809512
- Location
- San Diego, CA · TIN 89-4780194
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $298.00 | $184.76 | $20.00 | $164.76 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $18.00 | $11.16 | $0.00 | $11.16 | Paid |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $180.00 | $111.60 | $0.00 | $111.60 | Paid |
| Totals | $496.00 | $307.52 | $20.00 | $287.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-940743
- 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-004350 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-09: OPTIONS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 5 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 Mesa Family Practice (7652159394). | |
| 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: Mesa Family Practice2026-01-09 17:22
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
$496.00
Plan discount
$188.48
contracted rate
Plan paid
$287.52
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-2026-022060 | 2026-07-14 | Desert Rehabilitation Center | $318.00 | Needs review |
| CLM-2026-021979 | 2026-01-09 | Mesa Family Practice | $496.00 | Denied |
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.