Professional claim · CMS-1500 · EDI 837P
CLM-2026-032431
Heritage Medical Group, Internal Medicine. Service 2026-08-02 at office (POS 11). Received 2026-08-05.
Approved
Billed
$119.00
2 lines
Allowed
$73.78
contract rate applied
Plan pays
$39.68
approved
Member owes
$34.10
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jacob Jenkins
- Member ID
- UHC-53925-63
- Date of birth
- 1968-04-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-406839
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6851
- Coverage period
- 2024-01-01 to present
- Deductible
- $279.90 of $500.0056%
- Out-of-pocket maximum
- $134.74 of $1,000.0013%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 9266596391
- Location
- Austin, TX · TIN 10-1675475
- Authorisation / referral
- none / REF196733
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $55.00 | $34.10 | $34.10 | $0.00 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $64.00 | $39.68 | $0.00 | $39.68 | Paid |
| Totals | $119.00 | $73.78 | $34.10 | $39.68 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-287215
- 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-001875 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-02: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 3 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 Heritage Medical Group (5190573977). | |
| 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: Heritage Medical Group2026-08-02 17:44
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$119.00
Plan discount
$45.22
contracted rate
Plan paid
$39.68
You may owe
$34.10
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-2026-025557 | 2026-07-20 | Desert Primary Care Associates | $297.00 | 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.