Professional claim · CMS-1500 · EDI 837P
CLM-2026-029650
Desert Internal Medicine Associates, Internal Medicine. Service 2026-09-26 at office (POS 11). Received 2026-10-07.
Approved
Billed
$437.00
2 lines
Allowed
$270.94
contract rate applied
Plan pays
$240.94
approved
Member owes
$30.00
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
- Rachel Coleman
- Member ID
- UHC-34040-77
- Date of birth
- 1949-10-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-412546
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3693
- Coverage period
- 2021-02-01 to present
- Deductible
- $270.00 of $500.0054%
- Out-of-pocket maximum
- $369.69 of $1,000.0037%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 7171226260
- Location
- Mesa, AZ · TIN 70-7613029
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $391.00 | $242.42 | $30.00 | $212.42 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $46.00 | $28.52 | $0.00 | $28.52 | Paid |
| Totals | $437.00 | $270.94 | $30.00 | $240.94 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-728352
- 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-008858 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-26: OPTIONS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 11 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 Desert Internal Medicine Associates (6778439607). | |
| 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: Desert Internal Medicine Associates2026-09-26 14:35
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$437.00
Plan discount
$166.06
contracted rate
Plan paid
$240.94
You may owe
$30.00
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-2026-029651 | 2026-09-26 | Desert Internal Medicine Associates | $437.00 | Needs review |
| CLM-2026-033242 | 2026-09-21 | Meadow Reference Lab | $59.00 | Approved |
| CLM-2026-004146 | 2026-01-12 | Northgate Reference Lab | $181.00 | Needs review |
| CLM-2026-007664 | 2025-12-16 | Northgate Internal Medicine Associates | $232.00 | 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.