Professional claim · CMS-1500 · EDI 837P
CLM-2026-028307
Northgate Medical Group, Family Medicine. Service 2026-06-16 at office (POS 11). Received 2026-06-18.
Approved
Billed
$219.00
2 lines
Allowed
$135.78
contract rate applied
Plan pays
$95.78
approved
Member owes
$40.00
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
- Carlos Young
- Member ID
- UHC-07597-48
- Date of birth
- 2004-11-02
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-405036
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2971
- Coverage period
- 2021-03-01 to present
- Deductible
- $315.90 of $500.0063%
- Out-of-pocket maximum
- $236.47 of $1,500.0016%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3539927137
- Network
- In network
- Rendering NPI
- 5527907245
- Location
- Scottsdale, AZ · TIN 91-2030165
- 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 | $188.00 | $116.56 | $40.00 | $76.56 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $19.22 | $0.00 | $19.22 | Paid |
| Totals | $219.00 | $135.78 | $40.00 | $95.78 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-701064
- 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-035139 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-16: CORE-HMO (HMO), effective 2021-03-01. | |
| 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 | Pass | In-network provider Northgate Medical Group (3539927137). | |
| 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 Medical Group2026-06-16 14:09
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$219.00
Plan discount
$83.22
contracted rate
Plan paid
$95.78
You may owe
$40.00
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-2026-031996 | 2026-07-13 | Mesa Family Practice | $140.00 | Approved |
| CLM-2026-028904 | 2026-05-23 | Harbor Primary Care Associates | $495.00 | Denied |
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.