Professional claim · CMS-1500 · EDI 837P
CLM-2026-031970
Meadow Primary Care Associates, Family Medicine. Service 2026-09-10 at office (POS 11). Received 2026-10-12.
Approved
Billed
$463.00
3 lines
Allowed
$287.06
contract rate applied
Plan pays
$247.06
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Matthews Lori
- Member ID
- UHC-03231-10
- Date of birth
- 2000-11-13
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415172
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1495
- Coverage period
- 2024-10-01 to present
- Deductible
- $50.21 of $500.0010%
- Out-of-pocket maximum
- $190.68 of $1,000.0019%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8748622841
- Network
- In network
- Rendering NPI
- 2323420358
- Location
- Atlanta, GA · TIN 43-6231425
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $166.00 | $102.92 | $40.00 | $62.92 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $279.00 | $172.98 | $0.00 | $172.98 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1,2 | $18.00 | $11.16 | $0.00 | $11.16 | Paid |
| Totals | $463.00 | $287.06 | $40.00 | $247.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-364705
- 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-014744 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-10: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 32 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 Meadow Primary Care Associates (8748622841). | |
| 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: Meadow Primary Care Associates2026-09-10 09:17
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$463.00
Plan discount
$175.94
contracted rate
Plan paid
$247.06
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
No other claims.
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.