Professional claim · CMS-1500 · EDI 837P
CLM-2026-031671
Mesa Family Practice, Family Medicine. Service 2026-04-12 at office (POS 11). Received 2026-05-19.
Approved
Billed
$278.00
2 lines
Allowed
$172.36
contract rate applied
Plan pays
$132.36
approved
Member owes
$40.00
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
- Lucia Rios
- Member ID
- UHC-92720-51
- Date of birth
- 1939-04-02
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-428694
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8351
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,624.17 of $2,500.0065%
- Out-of-pocket maximum
- $1,945.07 of $7,500.0026%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 5427656322
- Location
- San Diego, CA · TIN 89-4780194
- 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 | $238.00 | $147.56 | $40.00 | $107.56 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $40.00 | $24.80 | $0.00 | $24.80 | Paid |
| Totals | $278.00 | $172.36 | $40.00 | $132.36 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-488538
- 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-006680 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-12: MEDICARE-ADV-B (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 37 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 Mesa Family Practice (7652159394). | |
| 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: Mesa Family Practice2026-04-12 14:54
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$278.00
Plan discount
$105.64
contracted rate
Plan paid
$132.36
You may owe
$40.00
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-2026-012460 | 2026-07-26 | Valley Skin Care Associates | $520.00 | Needs review |
| CLM-2026-000769 | 2026-08-03 | Mesa Medical Group | $442.00 | Approved |
| CLM-2026-005989 | 2026-06-15 | Canyon Clinical Laboratories | $59.00 | Approved |
| CLM-2026-031672 | 2026-04-12 | Mesa Family Practice | $278.00 | Denied |
| CLM-2026-007108 | 2026-02-26 | Mesa Clinical Laboratories | $128.00 | 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.