Professional claim · CMS-1500 · EDI 837P
CLM-2026-022380
Valley Bone and Joint Center, Orthopedic Surgery. Service 2025-12-29 at office (POS 11). Received 2026-01-23.
ApprovedOut of network
Billed
$151.00
1 line
Allowed
$67.95
contract rate applied
Plan pays
$17.95
approved
Member owes
$50.00
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
- Stephen Ford
- Member ID
- UHC-14624-83
- Date of birth
- 1974-03-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430689
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6316
- Coverage period
- 2024-05-01 to present
- Deductible
- $2,643.51 of $3,500.0076%
- Out-of-pocket maximum
- $2,559.83 of $7,000.0037%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 9793653152
- Network
- Out of network
- Rendering NPI
- 3481229219
- Location
- Mesa, AZ · TIN 68-9887889
- 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 | $151.00 | $67.95 | $50.00 | $17.95 | Paid |
| Totals | $151.00 | $67.95 | $50.00 | $17.95 | ||||||
Diagnoses (ICD-10-CM)
- 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
- 2. M25.561 Pain in right knee
Claim header
- Patient account
- PA-309796
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006968 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-29: CHOICE-PLUS-PPO (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 25 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Bone and Joint Center2025-12-29 11:19
Patient seen for unilateral primary osteoarthritis, right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$151.00
Plan discount
$83.05
out-of-network allowance
Plan paid
$17.95
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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-2026-019058 | 2026-02-22 | Unity Cardiovascular Associates | $622.00 | Approved |
| CLM-2026-022381 | 2025-12-29 | Valley Bone and Joint Center | $151.00 | 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.