Professional claim · CMS-1500 · Provider portal
CLM-2026-033958
Riverside Medical Group, Family Medicine. Service 2026-02-26 at office (POS 11). Received 2026-03-26.
Approved
Billed
$182.00
2 lines
Allowed
$112.84
contract rate applied
Plan pays
$92.84
approved
Member owes
$20.00
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
- Arthur Valdez
- Member ID
- UHC-18114-77
- Date of birth
- 1996-08-18
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-431737
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8591
- Coverage period
- 2025-05-01 to present
- Deductible
- $1,011.67 of $1,500.0067%
- Out-of-pocket maximum
- $878.09 of $4,500.0020%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8250558730
- Network
- In network
- Rendering NPI
- 4678393297
- Location
- Nashville, TN · TIN 54-5227365
- 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 | 90471 | Immunization administration | — | 1 | 1 | $40.00 | $24.80 | $20.00 | $4.80 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $142.00 | $88.04 | $0.00 | $88.04 | Paid |
| Totals | $182.00 | $112.84 | $20.00 | $92.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-444672
- 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-022227 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-26: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 28 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 Medical Group (8250558730). | |
| 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 Medical Group2026-02-26 10:52
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$182.00
Plan discount
$69.16
contracted rate
Plan paid
$92.84
You may owe
$20.00
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-2026-023313 | 2026-08-03 | Sunrise Skin Care Associates | $166.00 | Approved |
| CLM-2026-024039 | 2026-07-02 | Valley Medical Group | $318.00 | Approved |
| CLM-2026-008509 | 2026-06-30 | Pinecrest Medical Group | $284.00 | Approved |
| CLM-2026-019717 | 2026-04-26 | Meadow Family Practice | $417.00 | Approved |
| CLM-2026-033959 | 2026-02-26 | Riverside Medical Group | $182.00 | Needs review |
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.