Professional claim · CMS-1500 · Paper
CLM-2026-030756
Meadow Family Practice, Family Medicine. Service 2026-08-16 at office (POS 11). Received 2026-08-25.
Approved
Billed
$575.00
3 lines
Allowed
$356.50
contract rate applied
Plan pays
$326.50
approved
Member owes
$30.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Dennis Salazar
- Member ID
- UHC-90264-58
- Date of birth
- 1987-01-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412204
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5483
- Coverage period
- 2022-02-01 to present
- Deductible
- $645.50 of $1,000.0065%
- Out-of-pocket maximum
- $400.01 of $2,000.0020%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1613403900
- Network
- In network
- Rendering NPI
- 6188429875
- Location
- Atlanta, GA · TIN 74-8679615
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $335.00 | $207.70 | $30.00 | $177.70 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $203.00 | $125.86 | $0.00 | $125.86 | Paid |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $37.00 | $22.94 | $0.00 | $22.94 | Paid |
| Totals | $575.00 | $356.50 | $30.00 | $326.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-348932
- 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-024294 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-16: NAVIGATE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 9 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 Meadow Family Practice (1613403900). | |
| 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: Meadow Family Practice2026-08-16 16:09
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$575.00
Plan discount
$218.50
contracted rate
Plan paid
$326.50
You may owe
$30.00
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.