Professional claim · CMS-1500 · EDI 837P
CLM-2026-022595
Heritage Family Practice, Family Medicine. Service 2026-01-06 at office (POS 11). Received 2026-01-18.
Approved
Billed
$289.00
1 line
Allowed
$179.18
contract rate applied
Plan pays
$159.18
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
- Natalie McCoy
- Member ID
- UHC-26564-74
- Date of birth
- 2001-10-02
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-410071
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7528
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,409.41 of $3,500.0040%
- Out-of-pocket maximum
- $2,801.13 of $14,000.0020%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 9645451706
- Location
- Scottsdale, AZ · TIN 98-1410500
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $289.00 | $179.18 | $20.00 | $159.18 | Paid |
| Totals | $289.00 | $179.18 | $20.00 | $159.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-192405
- 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-001407 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-06: NAVIGATE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 12 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 Heritage Family Practice (3586851693). | |
| 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: Heritage Family Practice2026-01-06 11:09
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$289.00
Plan discount
$109.82
contracted rate
Plan paid
$159.18
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-2026-002996 | 2026-08-04 | Harbor Rehabilitation Center | $337.00 | Needs review |
| CLM-2026-002995 | 2026-08-04 | Harbor Rehabilitation Center | $337.00 | Approved |
| CLM-2026-021829 | 2026-06-08 | Canyon Reference Lab | $49.00 | Approved |
| CLM-2026-019766 | 2026-06-01 | Summit Regional Medical Center | $2,331.00 | Approved |
| CLM-2026-013733 | 2026-04-18 | Northgate Clinical Laboratories | $73.00 | Approved |
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.