Claims workbench/CLM-2026-028547
Professional claim · CMS-1500 · Provider portal

CLM-2026-028547

Summit Digestive Health Center, Gastroenterology. Service 2026-03-26 at office (POS 11). Received 2026-05-08.

Approved
Billed
$247.00
1 line
Allowed
$153.14
contract rate applied
Plan pays
$113.14
approved
Member owes
$40.00
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
Arthur Austin
Member ID
UHC-81712-05
Date of birth
1977-04-03
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-401581
Relationship
Child, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan
NULL PPO group GRP-5326
Coverage period
2025-01-01 to 2026-08-24
Deductible
$939.14 of $2,500.0038%
Out-of-pocket maximum
$2,834.07 of $7,500.0038%
Copays
office $40.00, specialist $40.00, emergency $250.00
Physical therapy visits
17 of 20 used

Provider

Billing and rendering

Billing provider
Summit Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
1126576986
Network
In network
Rendering NPI
5351700872
Location
Nashville, TN · TIN 32-9600100
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$247.00$153.14$40.00$113.14Paid
Totals$247.00$153.14$40.00$113.14
Diagnoses (ICD-10-CM)
  • 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
  • 2. K58.0 Irritable bowel syndrome with diarrhea
Claim header
Patient account
PA-607746
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

CheckResultCodeDetail
Member identityPassAttached to MBR-029737 (verified, link confidence 0.99).
EligibilityPassActive on 2026-03-26: NULL (PPO), effective 2025-01-01, terms 2026-08-24.
Timely filingPassReceived 43 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Digestive Health Center (1126576986).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Summit Digestive Health Center2026-03-26 17:41

    Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$247.00
Plan discount
$93.86
contracted rate
Plan paid
$113.14
You may owe
$40.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

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.

Review queueMember identity