Professional claim · CMS-1500 · EDI 837P
CLM-2026-027526
Heritage Primary Care Associates, Family Medicine. Service 2026-05-26 at office (POS 11). Received 2026-07-10.
Approved
Billed
$775.00
3 lines
Allowed
$480.50
contract rate applied
Plan pays
$460.50
approved
Member owes
$20.00
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
- Benjamin Ross
- Member ID
- UHC-35042-30
- Date of birth
- 1980-12-02
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407836
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9464
- Coverage period
- 2022-11-01 to present
- Deductible
- $500.67 of $2,500.0020%
- Out-of-pocket maximum
- $442.53 of $7,500.006%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2218360602
- Network
- In network
- Rendering NPI
- 1547295711
- Location
- Atlanta, GA · TIN 79-7884821
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $187.00 | $115.94 | $20.00 | $95.94 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $336.00 | $208.32 | $0.00 | $208.32 | Paid |
| 3 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $252.00 | $156.24 | $0.00 | $156.24 | Paid |
| Totals | $775.00 | $480.50 | $20.00 | $460.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-508256
- 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-035921 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-26: MEDICARE-ADV-B (MA), effective 2022-11-01. | |
| 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 Heritage Primary Care Associates (2218360602). | |
| 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: Heritage Primary Care Associates2026-05-26 13:44
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$775.00
Plan discount
$294.50
contracted rate
Plan paid
$460.50
You may owe
$20.00
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-2026-002084 | 2026-10-09 | Canyon Cardiovascular Associates | $246.00 | 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.