Claims workbench/CLM-2026-030827
Professional claim · CMS-1500 · EDI 837P

CLM-2026-030827

Evergreen Family Practice, Family Medicine. Service 2026-08-24 at office (POS 11). Received 2026-09-06.

Approved
Billed
$20.00
1 line
Allowed
$12.40
contract rate applied
Plan pays
$0.00
approved
Member owes
$12.40
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
Sophia Moreno
Member ID
UHC-86550-84
Date of birth
1956-07-12
Identity
Verified2 records, confidence 0.98
Claim record
CLMCLM-406755
Relationship
Spouse, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-9461
Coverage period
2024-12-01 to present
Deductible
$979.46 of $2,500.0039%
Out-of-pocket maximum
$1,637.52 of $5,000.0033%
Copays
office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits
10 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
1600303576
Network
In network
Rendering NPI
5499184468
Location
Los Angeles, CA · TIN 10-4370039
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$20.00$12.40$12.40$0.00Paid
Totals$20.00$12.40$12.40$0.00
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. I10 Essential (primary) hypertension
  • 3. E11.9 Type 2 diabetes mellitus without complications
Claim header
Patient account
PA-997390
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

CheckResultCodeDetail
Member identityPassAttached to MBR-031062 (verified, link confidence 0.98).
EligibilityPassActive on 2026-08-24: SELECT-EPO (EPO), effective 2024-12-01.
Timely filingPassReceived 13 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Family Practice (1600303576).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Evergreen Family Practice2026-08-24 09:05

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$20.00
Plan discount
$7.60
contracted rate
Plan paid
$0.00
You may owe
$12.40
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean 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.

Review queueMember identity