Professional claim · CMS-1500 · EDI 837P
CLM-2026-028179
Meadow Family Practice, Family Medicine. Service 2026-03-25 at office (POS 11). Received 2026-04-25.
Approved
Billed
$160.00
2 lines
Allowed
$99.20
contract rate applied
Plan pays
$90.52
approved
Member owes
$8.68
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Andrea Morrison
- Member ID
- UHC-35790-95
- Date of birth
- 1968-07-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428998
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8071
- Coverage period
- 2022-12-01 to present
- Deductible
- $115.02 of $1,000.0012%
- Out-of-pocket maximum
- $265.57 of $2,000.0013%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8614941473
- Network
- In network
- Rendering NPI
- 8962758156
- Location
- Atlanta, GA · TIN 64-8981661
- 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 | 36415 | Venipuncture | — | 1 | 1 | $14.00 | $8.68 | $8.68 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1 | $146.00 | $90.52 | $0.00 | $90.52 | Paid |
| Totals | $160.00 | $99.20 | $8.68 | $90.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-430092
- 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-017878 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-25: OPTIONS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 31 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 Family Practice (8614941473). | |
| 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: Meadow Family Practice2026-03-25 13:14
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$160.00
Plan discount
$60.80
contracted rate
Plan paid
$90.52
You may owe
$8.68
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013521 | 2026-09-12 | Canyon Reference Lab | $107.00 | 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.