Claims workbench/CLM-2026-022702
Professional claim · CMS-1500 · EDI 837P

CLM-2026-022702

Mesa Cardiovascular Associates, Cardiology. Service 2026-08-15 at office (POS 11). Received 2026-09-03.

Approved
Billed
$329.00
1 line
Allowed
$203.98
contract rate applied
Plan pays
$143.98
approved
Member owes
$60.00
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
Vincent Coook
Member ID
UHC-88788-90
Date of birth
2008-04-20
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-407745
Relationship
Spouse, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group NULL
Coverage period
2024-08-01 to present
Deductible
$2,163.91 of $2,500.0087%
Out-of-pocket maximum
$2,015.34 of $5,000.0040%
Copays
office $30.00, specialist $60.00, emergency $350.00
Physical therapy visits
9 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI
4876629211
Network
In network
Rendering NPI
3910866771
Location
Austin, TX · TIN 24-4510825
Authorisation / referral
none / REF991626

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$329.00$203.98$60.00$143.98Paid
Totals$329.00$203.98$60.00$143.98
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-523645
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-032233 (verified, link confidence 0.99).
EligibilityPassActive on 2026-08-15: CORE-HMO (HMO), effective 2024-08-01.
Timely filingPassReceived 19 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Cardiovascular Associates (4876629211).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Mesa Cardiovascular Associates2026-08-15 14:47

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$329.00
Plan discount
$125.02
contracted rate
Plan paid
$143.98
You may owe
$60.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity