Professional claim · CMS-1500 · EDI 837P
CLM-2026-031291
Unity Digestive Health Center, Gastroenterology. Service 2026-04-18 at office (POS 11). Received 2026-05-30.
Approved
Billed
$328.00
1 line
Allowed
$203.36
contract rate applied
Plan pays
$128.36
approved
Member owes
$75.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ryan Soto
- Member ID
- UHC-31409-02
- Date of birth
- 2002-11-11
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-423159
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0921
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,328.24 of $3,500.0038%
- Out-of-pocket maximum
- $2,647.88 of $10,500.0025%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 4682133804
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- none / REF426911
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $328.00 | $203.36 | $75.00 | $128.36 | Paid |
| Totals | $328.00 | $203.36 | $75.00 | $128.36 | ||||||
Diagnoses (ICD-10-CM)
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
Claim header
- Patient account
- PA-604848
- 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-025104 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-18: NAVIGATE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 42 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 Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-04-18 18:16
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$328.00
Plan discount
$124.64
contracted rate
Plan paid
$128.36
You may owe
$75.00
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-2026-027014 | 2026-03-03 | Northgate Orthopedic Specialists | $1,874.00 | Denied |
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.