Professional claim · CMS-1500 · EDI 837P
CLM-2026-028405
Harbor Endocrine Associates, Endocrinology. Service 2026-05-15 at office (POS 11). Received 2026-05-20.
Approved
Billed
$317.00
1 line
Allowed
$196.54
contract rate applied
Plan pays
$121.54
approved
Member owes
$75.00
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
- Dylan Rivera
- Member ID
- UHC-21374-40
- Date of birth
- 1988-12-22
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-413837
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4645
- Coverage period
- 2024-09-01 to present
- Deductible
- $740.43 of $1,000.0074%
- Out-of-pocket maximum
- $97.02 of $3,000.003%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 8826206194
- Network
- In network
- Rendering NPI
- 5520334389
- Location
- Nashville, TN · TIN 64-6622080
- Authorisation / referral
- none / REF669257
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $317.00 | $196.54 | $75.00 | $121.54 | Paid |
| Totals | $317.00 | $196.54 | $75.00 | $121.54 | ||||||
Diagnoses (ICD-10-CM)
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-114665
- 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-016240 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-15: CORE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 5 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 Endocrine Associates (8826206194). | |
| 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: Harbor Endocrine Associates2026-05-15 18:17
Patient seen for thyrotoxicosis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$317.00
Plan discount
$120.46
contracted rate
Plan paid
$121.54
You may owe
$75.00
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-2026-021958 | 2026-10-04 | Evergreen Reference Lab | $69.00 | Approved |
| CLM-2026-011142 | 2026-01-15 | Unity Reference Lab | $175.00 | 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.