Professional claim · CMS-1500 · EDI 837P
CLM-2026-033256
Unity Primary Care Associates, Family Medicine. Service 2026-10-01 at office (POS 11). Received 2026-10-17.
ApprovedOut of network
Billed
$453.00
3 lines
Allowed
$203.85
contract rate applied
Plan pays
$173.85
approved
Member owes
$30.00
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
- Scott Ward
- Member ID
- UHC-40403-01
- Date of birth
- 1943-10-21
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414793
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4024
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,925.69 of $3,500.0055%
- Out-of-pocket maximum
- $1,419.54 of $7,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8247321622
- Network
- Out of network
- Rendering NPI
- 8580696879
- Location
- Tempe, AZ · TIN 17-5198361
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $222.00 | $99.90 | $30.00 | $69.90 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1,2 | $202.00 | $90.90 | $0.00 | $90.90 | Paid |
| 3 | 90471 | Immunization administration | — | 1 | 1,2 | $29.00 | $13.05 | $0.00 | $13.05 | Paid |
| Totals | $453.00 | $203.85 | $30.00 | $173.85 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-765339
- 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-005999 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-10-01: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 16 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: Unity Primary Care Associates2026-10-01 13:37
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$453.00
Plan discount
$249.15
out-of-network allowance
Plan paid
$173.85
You may owe
$30.00
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-2026-010129 | 2026-09-26 | Sunrise Digestive Health Center | $229.00 | Needs review |
| CLM-2026-021275 | 2026-09-04 | Valley Skin Care Associates | $179.00 | 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.