Professional claim · CMS-1500 · EDI 837P
CLM-2026-023082
Heritage Primary Care Associates, Family Medicine. Service 2026-09-12 at office (POS 11). Received 2026-10-13.
Approved
Billed
$217.00
2 lines
Allowed
$134.54
contract rate applied
Plan pays
$124.62
approved
Member owes
$9.92
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
- Hiroshi Fowler
- Member ID
- UHC-09603-43
- Date of birth
- 1947-09-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419718
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1294
- Coverage period
- 2025-03-01 to present
- Deductible
- $235.66 of $500.0047%
- Out-of-pocket maximum
- $454.58 of $1,000.0045%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 8549891801
- Location
- San Diego, CA · TIN 62-9200818
- 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 | $16.00 | $9.92 | $9.92 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $201.00 | $124.62 | $0.00 | $124.62 | Paid |
| Totals | $217.00 | $134.54 | $9.92 | $124.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-319310
- 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-007174 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-12: CORE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 31 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 Primary Care Associates (8400209101). | |
| 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 Primary Care Associates2026-09-12 11:27
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$217.00
Plan discount
$82.46
contracted rate
Plan paid
$124.62
You may owe
$9.92
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-2026-023083 | 2026-09-12 | Heritage Primary Care Associates | $217.00 | Denied |
| CLM-2026-000670 | 2026-07-14 | Sunrise Community Hospital | $2,658.00 | 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.