Professional claim · CMS-1500 · EDI 837P
CLM-2026-022367
Harbor Primary Care Associates, Family Medicine. Service 2026-07-07 at office (POS 11). Received 2026-08-16.
ApprovedOut of network
Billed
$510.00
3 lines
Allowed
$229.50
contract rate applied
Plan pays
$223.20
approved
Member owes
$6.30
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
- Jonathan Reed
- Member ID
- UHC-35512-91
- Date of birth
- 1952-09-24
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-404087
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8975
- Coverage period
- 2022-05-01 to present
- Deductible
- $116.43 of $500.0023%
- Out-of-pocket maximum
- $819.86 of $2,000.0041%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4898939200
- Network
- Out of network
- Rendering NPI
- 4293987622
- Location
- Austin, TX · TIN 23-1128130
- 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 | 36415 | Venipuncture | — | 1 | 1 | $14.00 | $6.30 | $6.30 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $186.00 | $83.70 | $0.00 | $83.70 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $310.00 | $139.50 | $0.00 | $139.50 | Paid |
| Totals | $510.00 | $229.50 | $6.30 | $223.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-368818
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029838 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-07: CHOICE-PLUS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 40 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Harbor Primary Care Associates2026-07-07 12:54
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$510.00
Plan discount
$280.50
out-of-network allowance
Plan paid
$223.20
You may owe
$6.30
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001535 | 2026-07-25 | Sunrise Physical Therapy | $315.00 | 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.