Professional claim · CMS-1500 · EDI 837P
CLM-2026-030528
Desert Heart Institute, Cardiology. Service 2026-04-08 at office (POS 11). Received 2026-05-23.
Approved
Billed
$620.00
2 lines
Allowed
$384.40
contract rate applied
Plan pays
$334.40
approved
Member owes
$50.00
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
- Donaald Ramirez
- Member ID
- UHC-32962-76
- Date of birth
- 1983-09-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425811
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2850
- Coverage period
- 2024-11-01 to present
- Deductible
- $2,897.80 of $3,500.0083%
- Out-of-pocket maximum
- $2,800.89 of $14,000.0020%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 5724302786
- Location
- Mesa, AZ · TIN 39-5178200
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $352.00 | $218.24 | $50.00 | $168.24 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $268.00 | $166.16 | $0.00 | $166.16 | Paid |
| Totals | $620.00 | $384.40 | $50.00 | $334.40 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-231591
- 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-031983 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-08: MEDICARE-ADV-B (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 45 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 Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-04-08 14:54
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$620.00
Plan discount
$235.60
contracted rate
Plan paid
$334.40
You may owe
$50.00
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.