Professional claim · CMS-1500 · EDI 837P
CLM-2026-027459
Riverside Medical Group, Family Medicine. Service 2026-05-22 at office (POS 11). Received 2026-06-11.
Approved
Billed
$286.00
2 lines
Allowed
$177.32
contract rate applied
Plan pays
$159.96
approved
Member owes
$17.36
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Kayla Perkins
- Member ID
- UHC-03779-64
- Date of birth
- 1982-05-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428031
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2022-10-01 to present
- Deductible
- $601.23 of $1,000.0060%
- Out-of-pocket maximum
- $858.81 of $3,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8250558730
- Network
- In network
- Rendering NPI
- 4622606331
- Location
- Nashville, TN · TIN 54-5227365
- 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 | 90471 | Immunization administration | — | 1 | 1 | $28.00 | $17.36 | $17.36 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $258.00 | $159.96 | $0.00 | $159.96 | Paid |
| Totals | $286.00 | $177.32 | $17.36 | $159.96 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-100147
- 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-034437 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-22: MEDICARE-ADV-B (MA), effective 2022-10-01. | |
| 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 Riverside Medical Group (8250558730). | |
| 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: Riverside Medical Group2026-05-22 14:58
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$286.00
Plan discount
$108.68
contracted rate
Plan paid
$159.96
You may owe
$17.36
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
No other claims.
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.