Professional claim · CMS-1500 · EDI 837P
CLM-2026-026673
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-07-23 at office (POS 11). Received 2026-08-12.
Approved
Billed
$283.00
1 line
Allowed
$175.46
contract rate applied
Plan pays
$100.46
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Raymond Walsh
- Member ID
- UHC-09175-90
- Date of birth
- 1951-11-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400013
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7045
- Coverage period
- 2025-09-01 to present
- Deductible
- $981.92 of $1,500.0065%
- Out-of-pocket maximum
- $1,105.40 of $4,500.0025%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 6908622775
- Location
- Houston, TX · TIN 79-8590773
- 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 | $283.00 | $175.46 | $75.00 | $100.46 | Paid |
| Totals | $283.00 | $175.46 | $75.00 | $100.46 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
Claim header
- Patient account
- PA-484245
- 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-000241 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-23: N/A (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 20 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 Pinecrest Cardiovascular Associates (4926340728). | |
| 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: Pinecrest Cardiovascular Associates2026-07-23 09:57
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
$100.46
You may owe
$75.00
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-2026-022863 | 2026-06-21 | Northgate Clinical Laboratories | $135.00 | Approved |
| CLM-2026-029724 | 2025-12-29 | Canyon Internal Medicine Associates | $2,372.00 | Needs review |
| CLM-2026-011576 | 2025-12-04 | Mesa Reference Lab | $136.00 | Needs review |
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.