Professional claim · CMS-1500 · EDI 837P
CLM-2026-033477
Riverside Primary Care Associates, Family Medicine. Service 2026-03-07 at office (POS 11). Received 2026-04-06.
Approved
Billed
$532.00
2 lines
Allowed
$329.84
contract rate applied
Plan pays
$289.84
approved
Member owes
$40.00
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
- Samantha Nunez
- Member ID
- UHC-31120-14
- Date of birth
- 1990-02-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407991
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8102
- Coverage period
- 2022-04-01 to present
- Deductible
- $140.56 of $1,000.0014%
- Out-of-pocket maximum
- $883.13 of $3,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 8779655272
- Location
- Phoenix, AZ · TIN 77-3257014
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $290.00 | $179.80 | $40.00 | $139.80 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $242.00 | $150.04 | $0.00 | $150.04 | Paid |
| Totals | $532.00 | $329.84 | $40.00 | $289.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-141643
- 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-008099 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-07: SELECT-EPO (EPO), effective 2022-04-01. | |
| 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 Riverside Primary Care Associates (6920830281). | |
| 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: Riverside Primary Care Associates2026-03-07 13:28
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$532.00
Plan discount
$202.16
contracted rate
Plan paid
$289.84
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-2026-016137 | 2026-09-19 | Harbor Physical Therapy | $372.00 | Approved |
| CLM-2026-030901 | 2026-03-25 | Cornerstone Family Practice | $271.00 | Denied |
| CLM-2026-015311 | 2026-02-05 | Cornerstone Regional Medical Center | $2,664.00 | 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.