Claims workbench/CLM-2026-032387
Professional claim · CMS-1500 · EDI 837P

CLM-2026-032387

Heritage Medical Group, Internal Medicine. Service 2026-08-31 at office (POS 11). Received 2026-10-06.

Approved
Billed
$77.00
1 line
Allowed
$47.74
contract rate applied
Plan pays
$22.74
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Carolyn Palmer
Member ID
UHC-46515-10
Date of birth
2004-08-19
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-407461
Relationship
Self, Orlando, FL

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-5083
Coverage period
2023-07-01 to present
Deductible
$594.56 of $2,500.0024%
Out-of-pocket maximum
$511.38 of $7,500.007%
Copays
office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits
17 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
5190573977
Network
In network
Rendering NPI
3410580179
Location
Austin, TX · TIN 10-1675475
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$77.00$47.74$25.00$22.74Paid
Totals$77.00$47.74$25.00$22.74
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
  • 3. J44.9 COPD, unspecified
Claim header
Patient account
PA-181497
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

CheckResultCodeDetail
Member identityPassAttached to MBR-025234 (verified, link confidence 1.00).
EligibilityPassActive on 2026-08-31: N/A (PPO), effective 2023-07-01.
Timely filingPassReceived 36 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Medical Group (5190573977).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Heritage Medical Group2026-08-31 13:47

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$77.00
Plan discount
$29.26
contracted rate
Plan paid
$22.74
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean 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.

Review queueMember identity