Professional claim · CMS-1500 · EDI 837P
CLM-2026-033151
Heritage Medical Group, Internal Medicine. Service 2026-03-15 at office (POS 11). Received 2026-03-17.
Approved
Billed
$498.00
2 lines
Allowed
$308.76
contract rate applied
Plan pays
$268.76
approved
Member owes
$40.00
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
- Eric Willsi
- Member ID
- UHC-18969-07
- Date of birth
- 1956-05-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429847
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8318
- Coverage period
- 2021-04-01 to present
- Deductible
- $1,562.51 of $3,500.0045%
- Out-of-pocket maximum
- $3,285.28 of $7,000.0047%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 5607265704
- Location
- Austin, TX · TIN 10-1675475
- 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 | $389.00 | $241.18 | $40.00 | $201.18 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $109.00 | $67.58 | $0.00 | $67.58 | Paid |
| Totals | $498.00 | $308.76 | $40.00 | $268.76 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-290187
- 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-020342 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-15: MEDICARE-ADV-A (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 2 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Medical Group2026-03-15 18:14
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$498.00
Plan discount
$189.24
contracted rate
Plan paid
$268.76
You may owe
$40.00
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
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.