Professional claim · CMS-1500 · EDI 837P
CLM-2026-028228
Harbor Medical Group, Family Medicine. Service 2026-09-09 at office (POS 11). Received 2026-10-02.
Approved
Billed
$213.00
1 line
Allowed
$132.06
contract rate applied
Plan pays
$102.06
approved
Member owes
$30.00
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
- Robert Nichols
- Member ID
- UHC-85627-10
- Date of birth
- 1989-09-18
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-425880
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5204
- Coverage period
- 2025-06-01 to present
- Deductible
- $689.91 of $1,000.0069%
- Out-of-pocket maximum
- $650.79 of $4,000.0016%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1145537761
- Network
- In network
- Rendering NPI
- 9744670420
- Location
- Phoenix, AZ · TIN 88-8462048
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $213.00 | $132.06 | $30.00 | $102.06 | Paid |
| Totals | $213.00 | $132.06 | $30.00 | $102.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-301850
- 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-020281 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-09-09: MEDICARE-ADV-A (MA), effective 2025-06-01. | |
| Timely filing | Pass | Received 23 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 Harbor Medical Group (1145537761). | |
| 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: Harbor Medical Group2026-09-09 13:43
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
$213.00
Plan discount
$80.94
contracted rate
Plan paid
$102.06
You may owe
$30.00
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-2026-024480 | 2026-09-05 | Evergreen Orthopedic Specialists | $425.00 | Approved |
| CLM-2026-017243 | 2026-06-14 | Lakeside Internal Medicine Associates | $176.00 | 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.