Professional claim · CMS-1500 · EDI 837P
CLM-2026-025610
Valley Primary Care Associates, Family Medicine. Service 2026-08-19 at office (POS 11). Received 2026-09-15.
Approved
Billed
$283.00
2 lines
Allowed
$175.46
contract rate applied
Plan pays
$135.46
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jose Richardson
- Member ID
- UHC-61622-11
- Date of birth
- 1960-08-27
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-403134
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3840
- Coverage period
- 2021-12-01 to present
- Deductible
- $794.40 of $1,000.0079%
- Out-of-pocket maximum
- $755.43 of $2,000.0038%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7442240793
- Network
- In network
- Rendering NPI
- 3617196233
- Location
- Scottsdale, AZ · TIN 22-1174857
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $249.00 | $154.38 | $40.00 | $114.38 | Paid |
| 2 | 90471 | Immunization administration | 25 | 1 | 1 | $34.00 | $21.08 | $0.00 | $21.08 | Paid |
| Totals | $283.00 | $175.46 | $40.00 | $135.46 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-361955
- 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-004869 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-08-19: NAVIGATE-HMO (HMO), effective 2021-12-01. | |
| 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 Primary Care Associates (7442240793). | |
| 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: Valley Primary Care Associates2026-08-19 14:50
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$283.00
Plan discount
$107.54
contracted rate
Plan paid
$135.46
You may owe
$40.00
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-2026-029763 | 2026-08-06 | Meadow Physical Therapy | $179.00 | Denied |
| CLM-2026-014219 | 2026-07-29 | Mesa Family Practice | $259.00 | Needs review |
| CLM-2026-014218 | 2026-07-29 | Desert Medical Group | $259.00 | 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.