Professional claim · CMS-1500 · EDI 837P
CLM-2026-030279
Sunrise Medical Group, Family Medicine. Service 2026-02-15 at office (POS 11). Received 2026-02-22.
Approved
Billed
$423.00
2 lines
Allowed
$262.26
contract rate applied
Plan pays
$242.26
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Donna Coleman
- Member ID
- UHC-56324-15
- Date of birth
- 1942-10-15
- Identity
- Verified4 records, confidence 0.87
- Claim record
- CLMCLM-409709
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3827
- Coverage period
- 2025-09-01 to 2026-07-11
- Deductible
- $1,046.75 of $1,500.0070%
- Out-of-pocket maximum
- $559.50 of $4,500.0012%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7750705916
- Network
- In network
- Rendering NPI
- 6007490256
- Location
- Tampa, FL · TIN 44-4657025
- 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 | $220.00 | $136.40 | $20.00 | $116.40 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1,2 | $203.00 | $125.86 | $0.00 | $125.86 | Paid |
| Totals | $423.00 | $262.26 | $20.00 | $242.26 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-237941
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015119 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-02-15: NAVIGATE-HMO (HMO), effective 2025-09-01, terms 2026-07-11. | |
| Timely filing | Pass | Received 7 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 Sunrise Medical Group (7750705916). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Medical Group2026-02-15 10:48
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$423.00
Plan discount
$160.74
contracted rate
Plan paid
$242.26
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean 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.