Professional claim · CMS-1500 · EDI 837P
CLM-2026-027598
Northgate Primary Care Associates, Family Medicine. Service 2026-04-18 at office (POS 11). Received 2026-04-20.
ApprovedOut of network
Billed
$263.00
2 lines
Allowed
$118.35
contract rate applied
Plan pays
$106.65
approved
Member owes
$11.70
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Keith Duncan
- Member ID
- UHC-01148-15
- Date of birth
- 1907-02-04
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-400921
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1121
- Coverage period
- 2022-03-01 to present
- Deductible
- $245.72 of $2,500.0010%
- Out-of-pocket maximum
- $1,396.55 of $7,500.0019%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4637508332
- Network
- Out of network
- Rendering NPI
- 8660063842
- Location
- Minneapolis, MN · TIN 67-8207814
- 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 | $26.00 | $11.70 | $11.70 | $0.00 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $237.00 | $106.65 | $0.00 | $106.65 | Paid |
| Totals | $263.00 | $118.35 | $11.70 | $106.65 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-948887
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026816 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-18: CHOICE-PLUS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 2 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Primary Care Associates2026-04-18 14:43
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
$263.00
Plan discount
$144.65
out-of-network allowance
Plan paid
$106.65
You may owe
$11.70
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.