Professional claim · CMS-1500 · EDI 837P
CLM-2026-031132
Riverside Family Practice, Family Medicine. Service 2026-08-30 at office (POS 11). Received 2026-10-07.
Approved
Billed
$519.00
2 lines
Allowed
$321.78
contract rate applied
Plan pays
$301.78
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Diana Spencer
- Member ID
- UHC-15396-79
- Date of birth
- 1942-08-19
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-422213
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5366
- Coverage period
- 2024-10-01 to present
- Deductible
- $387.60 of $2,500.0016%
- Out-of-pocket maximum
- $1,755.96 of $5,000.0035%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1193895335
- Network
- In network
- Rendering NPI
- 5151762254
- Location
- Los Angeles, CA · TIN 66-7778652
- 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 | $232.00 | $143.84 | $20.00 | $123.84 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $287.00 | $177.94 | $0.00 | $177.94 | Paid |
| Totals | $519.00 | $321.78 | $20.00 | $301.78 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-411219
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009491 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-30: CHOICE-PLUS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 38 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 Riverside Family Practice (1193895335). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Family Practice2026-08-30 12:51
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
$519.00
Plan discount
$197.22
contracted rate
Plan paid
$301.78
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031133 | 2026-08-30 | Riverside Family Practice | $519.00 | Needs review |
| CLM-2026-008592 | 2026-04-19 | Riverside Primary Care Associates | $333.00 | Needs review |
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.