Member
7691
Billing provider
7566
DOS
2025-07-07
DB status
paid
Total charge
$290.08
Allowed
$150.34
Paid
$120.83
Member resp.
$29.51
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $290.08 | $150.34 | $120.83 |
Diagnoses: I50.9*E78.5E66.9G47.33
Agent chain trace
intake_validator7 tool call(s)provider_lookupprovider 7566: NPI 1700381852 (individual, 207R00000X) active242mseligibility_lookupmember 7691: enrolled in plan 25 (self_spouse) on 2025-07-07221mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)199mscode_lookupICD-10-CM I50.9: Heart failure unspecified (active)197mscode_lookupICD-10-CM E78.5: Hyperlipidemia unspecified (active)145mscode_lookupICD-10-CM E66.9: Obesity unspecified (active)138mscode_lookupICD-10-CM G47.33: Obstructive sleep apnea (active)194ms
eligibility1 tool call(s)eligibility_lookupmember 7691: enrolled in plan 25 (self_spouse) on 2025-07-07172ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2025-07-07147msncci_checkno NCCI PTP rule for S99213+S99213 on 2025-07-07164ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S99213 on 2025-07-07222ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.502026-04-26 01:48:43confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
213252
Member
7691
Provider
7566
Date(s) of Service
2025-07-07
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $290.08 | $150.34 | $139.74 | $120.83 | $29.51 |
| Totals | $290.08 | $150.34 | $139.74 | $120.83 | $29.51 |
This EOB reflects amounts on the claim record. For chain-proposed figures (which may differ when the chain used synthetic-rate fallback), see the agent trace above — pricing/v0.2.0 emits a
synthetic_rate_used risk_flag when fee schedule data was missing.pend_to_human on 2026-04-26 01:48:43 per policy 1.