Professional claim · CMS-1500 · EDI 837P
CLM-2026-031630
Evergreen Medical Group, Family Medicine. Service 2026-05-08 at office (POS 11). Received 2026-06-21.
Approved
Billed
$735.00
3 lines
Allowed
$455.70
contract rate applied
Plan pays
$415.70
approved
Member owes
$40.00
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
- Keith Graham
- Member ID
- UHC-75505-45
- Date of birth
- 1954-04-20
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-428481
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group -
- Coverage period
- 2024-12-01 to present
- Deductible
- $64.84 of $500.0013%
- Out-of-pocket maximum
- $667.18 of $1,500.0044%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5318093783
- Network
- In network
- Rendering NPI
- 2723875748
- Location
- Dallas, TX · TIN 84-3883832
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $204.00 | $126.48 | $40.00 | $86.48 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $256.00 | $158.72 | $0.00 | $158.72 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $275.00 | $170.50 | $0.00 | $170.50 | Paid |
| Totals | $735.00 | $455.70 | $40.00 | $415.70 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-781402
- 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-004957 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-08: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 44 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 Evergreen Medical Group (5318093783). | |
| 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: Evergreen Medical Group2026-05-08 14:43
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$735.00
Plan discount
$279.30
contracted rate
Plan paid
$415.70
You may owe
$40.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011910 | 2026-07-13 | Lakeside Physical Therapy | $509.00 | Approved |
| CLM-2026-008442 | 2026-01-14 | Heritage Internal Medicine Associates | $233.00 | 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.