Claims workbench/CLM-2026-025517
Professional claim · CMS-1500 · EDI 837P

CLM-2026-025517

Northgate Heart Institute, Cardiology. Service 2026-06-21 at office (POS 11). Received 2026-06-23.

Approved
Billed
$258.00
1 line
Allowed
$159.96
contract rate applied
Plan pays
$119.96
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
Henry McDonald
Member ID
UHC-31494-10
Date of birth
1973-10-15
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-410446
Relationship
Self, Tempe, AZ

Coverage and accumulators

Found by member ID

Plan
NULL PPO group UNKNOWN
Coverage period
2023-08-01 to present
Deductible
$474.09 of $1,000.0047%
Out-of-pocket maximum
$237.56 of $4,000.006%
Copays
office $25.00, specialist $40.00, emergency $350.00
Physical therapy visits
3 of 20 used

Provider

Billing and rendering

Billing provider
Northgate Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
5192135197
Network
In network
Rendering NPI
6064446928
Location
San Diego, CA · TIN 46-7688844
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193224Holter monitor, 48 hours—11$258.00$159.96$40.00$119.96Paid
Totals$258.00$159.96$40.00$119.96
Diagnoses (ICD-10-CM)
  • 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-976218
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-022986 (verified, link confidence 1.00).
EligibilityPassActive on 2026-06-21: NULL (PPO), effective 2023-08-01.
Timely filingPassReceived 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Northgate Heart Institute (5192135197).
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: Northgate Heart Institute2026-06-21 16:01

    Established patient presents with atherosclerotic heart disease of native coronary artery without angina; 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
$258.00
Plan discount
$98.04
contracted rate
Plan paid
$119.96
You may owe
$40.00
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