Professional claim · CMS-1500 · EDI 837P
CLM-2026-032782
Harbor Endocrine Associates, Endocrinology. Service 2026-06-14 at office (POS 11). Received 2026-07-18.
Approved
Billed
$796.00
3 lines
Allowed
$493.52
contract rate applied
Plan pays
$453.52
approved
Member owes
$40.00
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
- Ralph Larson
- Member ID
- UHC-56641-79
- Date of birth
- 1978-06-24
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-427653
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2645
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,132.26 of $3,500.0032%
- Out-of-pocket maximum
- $2,904.51 of $10,500.0028%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 8826206194
- Network
- In network
- Rendering NPI
- 1972845667
- Location
- Nashville, TN · TIN 64-6622080
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $399.00 | $247.38 | $40.00 | $207.38 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $221.00 | $137.02 | $0.00 | $137.02 | Paid |
| 3 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 2 | $176.00 | $109.12 | $0.00 | $109.12 | Paid |
| Totals | $796.00 | $493.52 | $40.00 | $453.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-108851
- 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-012848 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-06-14: MEDICARE-ADV-B (MA), effective 2021-12-01. | |
| Timely filing | Pass | Received 34 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 Harbor Endocrine Associates (8826206194). | |
| 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: Harbor Endocrine Associates2026-06-14 16:37
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$796.00
Plan discount
$302.48
contracted rate
Plan paid
$453.52
You may owe
$40.00
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-2026-017917 | 2026-07-15 | Desert Regional Medical Center | $1,973.00 | Needs review |
| CLM-2026-017916 | 2026-07-15 | Desert Regional Medical Center | $1,973.00 | Approved |
| CLM-2026-025117 | 2026-01-14 | Northgate Primary Care Associates | $3,480.00 | 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.