Professional claim · CMS-1500 · EDI 837P
CLM-2026-026785
Sunrise Diabetes Center, Endocrinology. Service 2026-02-14 at office (POS 11). Received 2026-03-15.
Approved
Billed
$551.00
2 lines
Allowed
$341.62
contract rate applied
Plan pays
$281.62
approved
Member owes
$60.00
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
- Michelle Flores
- Member ID
- UHC-28380-51
- Date of birth
- 1961-10-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417518
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2917
- Coverage period
- 2024-01-01 to present
- Deductible
- $233.53 of $1,000.0023%
- Out-of-pocket maximum
- $542.91 of $2,000.0027%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 1154539146
- Network
- In network
- Rendering NPI
- 4372254761
- Location
- Tampa, FL · TIN 90-8967175
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $324.00 | $200.88 | $60.00 | $140.88 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $227.00 | $140.74 | $0.00 | $140.74 | Paid |
| Totals | $551.00 | $341.62 | $60.00 | $281.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
Claim header
- Patient account
- PA-300681
- 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-007222 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-14: SELECT-EPO (EPO), effective 2024-01-01. | |
| 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 Sunrise Diabetes Center (1154539146). | |
| 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: Sunrise Diabetes Center2026-02-14 15:20
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
$551.00
Plan discount
$209.38
contracted rate
Plan paid
$281.62
You may owe
$60.00
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-2026-032783 | 2026-01-17 | Riverside Community Hospital | $3,548.00 | 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.