Professional claim · CMS-1500 · Paper
CLM-2026-022869
Desert Family Practice, Family Medicine. Service 2026-02-13 at office (POS 11). Received 2026-03-08.
Approved
Billed
$265.00
2 lines
Allowed
$164.30
contract rate applied
Plan pays
$144.30
approved
Member owes
$20.00
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
- Omar Morgan
- Member ID
- UHC-12296-96
- Date of birth
- 1985-09-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413229
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4463
- Coverage period
- 2024-08-01 to present
- Deductible
- $2,407.21 of $3,500.0069%
- Out-of-pocket maximum
- $533.72 of $10,500.005%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8144042321
- Network
- In network
- Rendering NPI
- 3875005225
- Location
- Miami, FL · TIN 86-4678898
- 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 | $241.00 | $149.42 | $20.00 | $129.42 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $24.00 | $14.88 | $0.00 | $14.88 | Paid |
| Totals | $265.00 | $164.30 | $20.00 | $144.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-348140
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018304 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-13: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 23 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 Desert Family Practice (8144042321). | |
| 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: Desert Family Practice2026-02-13 09:33
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$265.00
Plan discount
$100.70
contracted rate
Plan paid
$144.30
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean 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.