Professional claim · CMS-1500 · EDI 837P
CLM-2026-029215
Evergreen Family Practice, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-05-20.
Approved
Billed
$370.00
3 lines
Allowed
$229.40
contract rate applied
Plan pays
$217.62
approved
Member owes
$11.78
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Roger Ross
- Member ID
- UHC-76258-52
- Date of birth
- 2000-12-27
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-428832
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0648
- Coverage period
- 2022-03-01 to present
- Deductible
- $324.05 of $2,500.0013%
- Out-of-pocket maximum
- $4,467.69 of $10,000.0045%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5857456904
- Network
- In network
- Rendering NPI
- 1233882186
- Location
- Austin, TX · TIN 44-5200426
- 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 | 36415 | Venipuncture | — | 1 | 1 | $19.00 | $11.78 | $11.78 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1,2 | $191.00 | $118.42 | $0.00 | $118.42 | Paid |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $160.00 | $99.20 | $0.00 | $99.20 | Paid |
| Totals | $370.00 | $229.40 | $11.78 | $217.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-159999
- 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-022138 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-12: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 8 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 Evergreen Family Practice (5857456904). | |
| 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: Evergreen Family Practice2026-05-12 16:41
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
$370.00
Plan discount
$140.60
contracted rate
Plan paid
$217.62
You may owe
$11.78
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-2026-025859 | 2026-03-01 | Heritage Rehabilitation Center | $380.00 | 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.