Member
8017
Billing provider
4974
DOS
2025-07-05
DB status
paid
Total charge
$109.97
Allowed
$44.21
Paid
$41.83
Member resp.
$2.38
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S90834 | 1 | $109.97 | $44.21 | $41.83 |
Diagnoses: F41.1*N18.3
Agent chain trace
intake_validator5 tool call(s)provider_lookupprovider 4974: NPI 1356586994 (individual, 207RC0000X) active161mseligibility_lookupmember 8017: enrolled in plan 18 (self_spouse) on 2025-07-05200mscode_lookupCPT S90834: Synthetic Psychotherapy 45 Minutes (active)276mscode_lookupICD-10-CM F41.1: Generalized anxiety disorder (active)228mscode_lookupICD-10-CM N18.3: Chronic kidney disease stage 3 (active)177ms
eligibility1 tool call(s)eligibility_lookupmember 8017: enrolled in plan 18 (self_spouse) on 2025-07-05209ms
coding_edits2 tool call(s)mue_checkno MUE rule for S90834 on 2025-07-05215msncci_checkno NCCI PTP rule for S90834+S90834 on 2025-07-05182ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S90834 on 2025-07-05158ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.502026-04-26 01:48:08confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
224424
Member
8017
Provider
4974
Date(s) of Service
2025-07-05
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S90834 | $109.97 | $44.21 | $65.76 | $41.83 | $2.38 |
| Totals | $109.97 | $44.21 | $65.76 | $41.83 | $2.38 |
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 01:48:08 per policy 1.