Professional claim · CMS-1500 · EDI 837P
CLM-2026-027568
Unity Internal Medicine Associates, Internal Medicine. Service 2026-01-30 at office (POS 11). Received 2026-02-07.
ApprovedOut of network
Billed
$730.00
3 lines
Allowed
$328.50
contract rate applied
Plan pays
$288.50
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Brenda Stephens
- Member ID
- UHC-21755-58
- Date of birth
- 1963-11-26
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-408347
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2617
- Coverage period
- 2025-08-01 to present
- Deductible
- $164.86 of $1,500.0011%
- Out-of-pocket maximum
- $331.53 of $4,500.007%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 1255472221
- Location
- Atlanta, GA · TIN 10-7193981
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $94.00 | $42.30 | $40.00 | $2.30 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $303.00 | $136.35 | $0.00 | $136.35 | Paid |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $333.00 | $149.85 | $0.00 | $149.85 | Paid |
| Totals | $730.00 | $328.50 | $40.00 | $288.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-869205
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011066 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-30: MEDICARE-ADV-B (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 8 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Internal Medicine Associates2026-01-30 12:16
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$730.00
Plan discount
$401.50
out-of-network allowance
Plan paid
$288.50
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014974 | 2026-08-12 | Heritage Internal Medicine Associates | $143.00 | Approved |
| CLM-2026-020721 | 2026-05-11 | Meadow Heart Institute | $7,075.00 | 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.