Claims workbench/CLM-2026-028747
Professional claim · CMS-1500 · Paper

CLM-2026-028747

Riverside Family Practice, Family Medicine. Service 2026-02-11 at office (POS 11). Received 2026-03-08.

Approved
Billed
$224.00
1 line
Allowed
$138.88
contract rate applied
Plan pays
$118.88
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Sophia Rios
Member ID
UHC-48900-43
Date of birth
1975-04-07
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-405428
Relationship
Self, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan
NULL PPO group GRP-4310
Coverage period
2022-01-01 to present
Deductible
$1,314.38 of $1,500.0088%
Out-of-pocket maximum
$2,082.84 of $4,500.0046%
Copays
office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits
12 of 20 used

Provider

Billing and rendering

Billing provider
Riverside Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
1193895335
Network
In network
Rendering NPI
4540186861
Location
Los Angeles, CA · TIN 66-7778652
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199203Office visit, new patient, low complexity—11$224.00$138.88$20.00$118.88Paid
Totals$224.00$138.88$20.00$118.88
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. J06.9 Acute upper respiratory infection, unspecified
  • 3. E11.9 Type 2 diabetes mellitus without complications
Claim header
Patient account
PA-197701
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-018301 (verified, link confidence 1.00).
EligibilityPassActive on 2026-02-11: NULL (PPO), effective 2022-01-01.
Timely filingPassReceived 25 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Family Practice (1193895335).
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: Riverside Family Practice2026-02-11 14:39

    Established patient presents with essential (primary) hypertension; 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
$224.00
Plan discount
$85.12
contracted rate
Plan paid
$118.88
You may owe
$20.00
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