Professional claim · CMS-1500 · EDI 837P
CLM-2026-030840
Heritage Medical Group, Family Medicine. Service 2025-11-19 at office (POS 11). Received 2026-01-03.
ApprovedOut of network
Billed
$579.00
3 lines
Allowed
$260.55
contract rate applied
Plan pays
$235.55
approved
Member owes
$25.00
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
- Brian Garcia
- Member ID
- none on golden record
- Date of birth
- 1978-07-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-416015
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-8461
- Coverage period
- 2025-06-01 to present
- Deductible
- $770.57 of $1,000.0077%
- Out-of-pocket maximum
- $1,199.63 of $3,000.0040%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 1795988892
- Location
- Denver, CO · TIN 49-9592909
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $227.00 | $102.15 | $25.00 | $77.15 | Paid |
| 2 | 36415 | Venipuncture | 25 | 1 | 1,2 | $20.00 | $9.00 | $0.00 | $9.00 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $332.00 | $149.40 | $0.00 | $149.40 | Paid |
| Totals | $579.00 | $260.55 | $25.00 | $235.55 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-329808
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000907 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2025-11-19: MEDICARE-ADV-B (MA), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Heritage Medical Group2025-11-19 17:37
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
$579.00
Plan discount
$318.45
out-of-network allowance
Plan paid
$235.55
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2025-11-19: MEDICARE-ADV-B (MA), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021582 | 2026-02-09 | Mesa Family Practice | $172.00 | Approved |
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.