Professional claim · CMS-1500 · EDI 837P
CLM-2026-034286
Unity Medical Group, Internal Medicine. Service 2026-01-25 at office (POS 11). Received 2026-02-23.
Approved
Billed
$52.00
1 line
Allowed
$32.24
contract rate applied
Plan pays
$7.24
approved
Member owes
$25.00
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
- Robert Robinson
- Member ID
- UHC-71882-37
- Date of birth
- 1988-10-05
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-429563
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8155
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,266.97 of $3,500.0036%
- Out-of-pocket maximum
- $3,565.28 of $14,000.0025%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 5928926125
- Location
- Mesa, AZ · TIN 43-9161942
- Authorisation / referral
- none / REF716906
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $52.00 | $32.24 | $25.00 | $7.24 | Paid |
| Totals | $52.00 | $32.24 | $25.00 | $7.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-403576
- 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-000165 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-25: CORE-HMO (HMO), effective 2021-12-01. | |
| Timely filing | Pass | Received 29 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 Unity Medical Group (1355996814). | |
| 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 Medical Group2026-01-25 10:33
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$52.00
Plan discount
$19.76
contracted rate
Plan paid
$7.24
You may owe
$25.00
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-2026-005233 | 2026-09-14 | Heritage Physical Therapy | $259.00 | Approved |
| CLM-2026-034287 | 2026-01-25 | Unity Medical Group | $52.00 | Needs review |
| CLM-2026-022541 | 2026-02-04 | Meadow Family Practice | $251.00 | Denied |
| CLM-2026-022540 | 2026-02-04 | Meadow Family Practice | $251.00 | 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.