Professional claim · CMS-1500 · EDI 837P
CLM-2026-030270
Desert Internal Medicine Associates, Internal Medicine. Service 2026-02-09 at office (POS 11). Received 2026-02-15.
Approved
Billed
$386.00
2 lines
Allowed
$239.32
contract rate applied
Plan pays
$199.32
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
- Anna Baker
- Member ID
- UHC-10154-58
- Date of birth
- 1944-10-27
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416436
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3642
- Coverage period
- 2022-06-01 to present
- Deductible
- $336.94 of $1,000.0034%
- Out-of-pocket maximum
- $623.61 of $2,000.0031%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 9387424416
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $313.00 | $194.06 | $40.00 | $154.06 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $73.00 | $45.26 | $0.00 | $45.26 | Paid |
| Totals | $386.00 | $239.32 | $40.00 | $199.32 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-298795
- 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-005724 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-09: OPTIONS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 6 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 Associates2026-02-09 15:00
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$386.00
Plan discount
$146.68
contracted rate
Plan paid
$199.32
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-2026-022987 | 2026-09-05 | Heritage Family Practice | $508.00 | Approved |
| CLM-2026-014829 | 2026-07-15 | Summit Regional Medical Center | $1,653.00 | Approved |
| CLM-2026-003578 | 2026-06-09 | Unity Community Hospital | $3,209.00 | Approved |
| CLM-2026-030271 | 2026-02-09 | Desert Internal Medicine Associates | $386.00 | Denied |
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.