Professional claim · CMS-1500 · EDI 837P
CLM-2026-032861
Evergreen Family Practice, Family Medicine. Service 2026-03-28 at office (POS 11). Received 2026-04-27.
Approved
Billed
$212.00
2 lines
Allowed
$131.44
contract rate applied
Plan pays
$101.44
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Mariana Collins
- Member ID
- UHC-57189-74
- Date of birth
- 1966-09-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-403205
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4009
- Coverage period
- 2025-10-01 to present
- Deductible
- $318.95 of $3,500.009%
- Out-of-pocket maximum
- $4,760.06 of $14,000.0034%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9703652849
- Network
- In network
- Rendering NPI
- 5751936241
- Location
- Miami, FL · TIN 83-6828766
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $180.00 | $111.60 | $30.00 | $81.60 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $32.00 | $19.84 | $0.00 | $19.84 | Paid |
| Totals | $212.00 | $131.44 | $30.00 | $101.44 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-132474
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021656 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-28: SELECT-EPO (EPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 30 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 Evergreen Family Practice (9703652849). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Family Practice2026-03-28 16:46
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
$212.00
Plan discount
$80.56
contracted rate
Plan paid
$101.44
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003292 | 2026-04-03 | Evergreen Orthopedic Specialists | $400.00 | 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.