Professional claim · CMS-1500 · EDI 837P
CLM-2026-027009
Meadow Primary Care Associates, Family Medicine. Service 2026-06-06 at office (POS 11). Received 2026-07-21.
Approved
Billed
$275.00
2 lines
Allowed
$170.50
contract rate applied
Plan pays
$140.50
approved
Member owes
$30.00
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
- Ralph Knight
- Member ID
- UHC-26304-24
- Date of birth
- 1998-02-15
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-423430
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2665
- Coverage period
- 2023-12-01 to present
- Deductible
- $466.53 of $2,500.0019%
- Out-of-pocket maximum
- $568.08 of $5,000.0011%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5061732918
- Network
- In network
- Rendering NPI
- 9182065620
- Location
- Scottsdale, AZ · TIN 54-2819857
- 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 | $259.00 | $160.58 | $30.00 | $130.58 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $16.00 | $9.92 | $0.00 | $9.92 | Paid |
| Totals | $275.00 | $170.50 | $30.00 | $140.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-406894
- 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-005177 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-06: CORE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 45 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 Meadow Primary Care Associates (5061732918). | |
| 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: Meadow Primary Care Associates2026-06-06 15:57
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$275.00
Plan discount
$104.50
contracted rate
Plan paid
$140.50
You may owe
$30.00
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-2026-026365 | 2026-06-16 | Sunrise Internal Medicine Associates | $252.00 | Approved |
| CLM-2026-020160 | 2026-06-21 | Desert Internal Medicine Associates | $367.00 | Approved |
| CLM-2026-027089 | 2026-03-22 | Summit Reference Lab | $165.00 | Approved |
| CLM-2026-026850 | 2025-12-26 | Heritage Digestive Health Center | $4,235.00 | 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.