Professional claim · CMS-1500 · EDI 837P
CLM-2026-026751
Desert Primary Care Associates, Family Medicine. Service 2026-07-27 at office (POS 11). Received 2026-08-25.
Approved
Billed
$319.00
2 lines
Allowed
$197.78
contract rate applied
Plan pays
$167.78
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Steve Wallace
- Member ID
- UHC-15113-79
- Date of birth
- 1940-10-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-427457
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9366
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,016.01 of $3,500.0029%
- Out-of-pocket maximum
- $4,921.76 of $14,000.0035%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8080835506
- Network
- In network
- Rendering NPI
- 1402059350
- Location
- Denver, CO · TIN 39-5381376
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $298.00 | $184.76 | $30.00 | $154.76 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $21.00 | $13.02 | $0.00 | $13.02 | Paid |
| Totals | $319.00 | $197.78 | $30.00 | $167.78 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-449698
- 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-035405 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-27: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 29 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 Desert Primary Care Associates (8080835506). | |
| 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: Desert Primary Care Associates2026-07-27 18:55
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$319.00
Plan discount
$121.22
contracted rate
Plan paid
$167.78
You may owe
$30.00
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-2026-030959 | 2026-06-15 | Unity Cardiovascular Associates | $5,200.00 | 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.