Professional claim · CMS-1500 · EDI 837P
CLM-2026-033938
Unity Primary Care Associates, Family Medicine. Service 2026-05-18 at office (POS 11). Received 2026-06-28.
ApprovedOut of network
Billed
$494.00
3 lines
Allowed
$222.30
contract rate applied
Plan pays
$182.30
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
- Sharon Stevens
- Member ID
- UHC-10278-31
- Date of birth
- 1985-05-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-415668
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4005
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,830.89 of $3,500.0052%
- Out-of-pocket maximum
- $2,447.80 of $14,000.0017%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 1547880348
- Location
- Charlotte, NC · TIN 92-2641302
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $170.00 | $76.50 | $40.00 | $36.50 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $28.00 | $12.60 | $0.00 | $12.60 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1,2 | $296.00 | $133.20 | $0.00 | $133.20 | Paid |
| Totals | $494.00 | $222.30 | $40.00 | $182.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-540540
- 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-001058 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-18: MEDICARE-ADV-B (MA), effective 2025-03-01. | |
| Timely filing | Pass | Received 41 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 Associates2026-05-18 18:14
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$494.00
Plan discount
$271.70
out-of-network allowance
Plan paid
$182.30
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 13:43Provider 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-2026-003877 | 2026-03-09 | Riverside Imaging Center | $419.00 | 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.