Professional claim · CMS-1500 · EDI 837P
CLM-2026-032408
Mesa Diabetes Center, Endocrinology. Service 2026-02-03 at office (POS 11). Received 2026-03-20.
Approved
Billed
$197.00
2 lines
Allowed
$122.14
contract rate applied
Plan pays
$47.14
approved
Member owes
$75.00
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
- Sharon Patterson
- Member ID
- UHC-01025-68
- Date of birth
- 1968-01-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401913
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9036
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,843.54 of $2,500.0074%
- Out-of-pocket maximum
- $3,045.72 of $7,500.0041%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 2446853584
- Network
- In network
- Rendering NPI
- 6650692992
- Location
- Denver, CO · TIN 89-4122070
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $136.00 | $84.32 | $75.00 | $9.32 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $61.00 | $37.82 | $0.00 | $37.82 | Paid |
| Totals | $197.00 | $122.14 | $75.00 | $47.14 | ||||||
Diagnoses (ICD-10-CM)
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-960727
- 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-020996 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-03: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 45 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 Diabetes Center (2446853584). | |
| 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 Diabetes Center2026-02-03 14:02
Patient seen for thyrotoxicosis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$197.00
Plan discount
$74.86
contracted rate
Plan paid
$47.14
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-2026-027168 | 2026-10-07 | Heritage Community Hospital | $1,247.00 | Approved |
| CLM-2026-023321 | 2026-07-17 | Canyon Medical Group | $87.00 | 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.