Professional claim · CMS-1500 · EDI 837P
CLM-2026-022346
Valley Primary Care Associates, Family Medicine. Service 2026-01-31 at office (POS 11). Received 2026-03-04.
Approved
Billed
$55.00
2 lines
Allowed
$34.10
contract rate applied
Plan pays
$14.10
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Melissa Cruz
- Member ID
- UHC-43441-53
- Date of birth
- 1996-09-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-401451
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8548
- Coverage period
- 2022-11-01 to present
- Deductible
- $568.41 of $1,500.0038%
- Out-of-pocket maximum
- $656.96 of $3,000.0022%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7442240793
- Network
- In network
- Rendering NPI
- 8584251986
- Location
- Scottsdale, AZ · TIN 22-1174857
- 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 | 90471 | Immunization administration | — | 1 | 1 | $38.00 | $23.56 | $20.00 | $3.56 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $17.00 | $10.54 | $0.00 | $10.54 | Paid |
| Totals | $55.00 | $34.10 | $20.00 | $14.10 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-451788
- 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-017340 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-31: OPTIONS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 32 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 Valley Primary Care Associates (7442240793). | |
| 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: Valley Primary Care Associates2026-01-31 10:44
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
$55.00
Plan discount
$20.90
contracted rate
Plan paid
$14.10
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-2026-011882 | 2026-09-19 | Riverside Primary Care Associates | $140.00 | Approved |
| CLM-2026-005626 | 2026-08-06 | Heritage Community Hospital | $218.00 | Approved |
| CLM-2026-028503 | 2026-07-12 | Mesa Medical Group | $3,132.00 | 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.