Claims workbench/CLM-2026-033009
Professional claim · CMS-1500 · EDI 837P

CLM-2026-033009

Mesa Family Practice, Family Medicine. Service 2026-01-14 at office (POS 11). Received 2026-01-31.

Approved
Billed
$14.00
1 line
Allowed
$8.68
contract rate applied
Plan pays
$0.00
approved
Member owes
$8.68
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
Albert Dean
Member ID
UHC-88054-86
Date of birth
1990-11-20
Identity
Verified4 records, confidence 1.00
Claim record
CLMCLM-419919
Relationship
Spouse, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-1850
Coverage period
2022-03-01 to present
Deductible
$285.45 of $500.0057%
Out-of-pocket maximum
$18.13 of $2,000.001%
Copays
office $30.00, specialist $40.00, emergency $150.00
Physical therapy visits
14 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
7916099477
Network
In network
Rendering NPI
1097317253
Location
Miami, FL · TIN 48-0020072
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$14.00$8.68$8.68$0.00Paid
Totals$14.00$8.68$8.68$0.00
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. J06.9 Acute upper respiratory infection, unspecified
  • 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
Patient account
PA-421276
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

CheckResultCodeDetail
Member identityPassAttached to MBR-004975 (verified, link confidence 1.00).
EligibilityPassActive on 2026-01-14: CHOICE-PLUS-PPO (PPO), effective 2022-03-01.
Timely filingPassReceived 17 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Family Practice (7916099477).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Family Practice2026-01-14 11:01

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$14.00
Plan discount
$5.32
contracted rate
Plan paid
$0.00
You may owe
$8.68
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity