Professional claim · CMS-1500 · EDI 837P
CLM-2026-030081
Pinecrest Bone and Joint Center, Orthopedic Surgery. Service 2026-01-16 at office (POS 11). Received 2026-01-30.
Approved
Billed
$189.00
1 line
Allowed
$117.18
contract rate applied
Plan pays
$77.18
approved
Member owes
$40.00
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
- Scott Gilbert
- Member ID
- UHC-73546-71
- Date of birth
- 1940-05-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-412397
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9067
- Coverage period
- 2025-08-01 to present
- Deductible
- $150.57 of $1,500.0010%
- Out-of-pocket maximum
- $226.05 of $3,000.008%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 2148364427
- Network
- In network
- Rendering NPI
- 2613952391
- Location
- Tampa, FL · TIN 14-7269323
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $189.00 | $117.18 | $40.00 | $77.18 | Paid |
| Totals | $189.00 | $117.18 | $40.00 | $77.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. S83.241A Other tear of medial meniscus, right knee, initial encounter
Claim header
- Patient account
- PA-959801
- 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-008989 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-16: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 14 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 Pinecrest Bone and Joint Center (2148364427). | |
| 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: Pinecrest Bone and Joint Center2026-01-16 17:13
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$189.00
Plan discount
$71.82
contracted rate
Plan paid
$77.18
You may owe
$40.00
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-2026-019372 | 2026-09-11 | Harbor Medical Group | $176.00 | Approved |
| CLM-2026-001962 | 2026-09-17 | Harbor Medical Group | $215.00 | 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.