Professional claim · CMS-1500 · EDI 837P
CLM-2026-023925
Valley Family Practice, Family Medicine. Service 2026-06-14 at office (POS 11). Received 2026-07-11.
Approved
Billed
$165.00
2 lines
Allowed
$102.30
contract rate applied
Plan pays
$62.30
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Edward Matthews
- Member ID
- UHC-66081-91
- Date of birth
- 1984-03-21
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409630
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0686
- Coverage period
- 2021-11-01 to present
- Deductible
- $744.93 of $3,500.0021%
- Out-of-pocket maximum
- $1,137.77 of $14,000.008%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 9309626494
- Location
- Houston, TX · TIN 34-3279519
- 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 | $140.00 | $86.80 | $40.00 | $46.80 | Paid |
| 2 | 36415 | Venipuncture | 25 | 1 | 1 | $25.00 | $15.50 | $0.00 | $15.50 | Paid |
| Totals | $165.00 | $102.30 | $40.00 | $62.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
Claim header
- Patient account
- PA-957480
- 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-029844 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-14: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 27 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 Valley Family Practice (3411841638). | |
| 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: Valley Family Practice2026-06-14 18:29
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$165.00
Plan discount
$62.70
contracted rate
Plan paid
$62.30
You may owe
$40.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030993 | 2026-04-02 | Canyon Diagnostic Imaging | $2,611.00 | Denied |
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.