Professional claim · CMS-1500 · EDI 837P
CLM-2026-032772
Valley Primary Care Associates, Family Medicine. Service 2026-04-17 at office (POS 11). Received 2026-06-01.
ApprovedOut of network
Billed
$41.00
1 line
Allowed
$18.45
contract rate applied
Plan pays
$0.00
approved
Member owes
$18.45
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
- Stephanie Porter
- Member ID
- UHC-82341-82
- Date of birth
- 1974-01-20
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-424232
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5274
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,765.04 of $3,500.0050%
- Out-of-pocket maximum
- $1,513.99 of $7,000.0022%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 2516085323
- Location
- Denver, CO · TIN 69-3521502
- 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 | 90471 | Immunization administration | — | 1 | 1 | $41.00 | $18.45 | $18.45 | $0.00 | Paid |
| Totals | $41.00 | $18.45 | $18.45 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-854988
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005935 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-17: MEDICARE-ADV-B (MA), effective 2025-03-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Primary Care Associates2026-04-17 12:15
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$41.00
Plan discount
$22.55
out-of-network allowance
Plan paid
$0.00
You may owe
$18.45
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032650 | 2025-12-09 | Riverside Cardiovascular Associates | $3,280.00 | Needs review |
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.