Member
8412
Billing provider
4753
DOS
2025-12-31
DB status
denied
Total charge
$2074.93
Allowed
$1132.07
Paid
$0.00
Member resp.
$1132.07
Claim lines (2)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | G0008 | 1 | $1243.62 | $687.80 | $0.00 | |
| 2 | S90658 | 1 | $831.31 | $444.27 | $0.00 |
Diagnoses: Z23*
Agent chain trace
intake_validator28 tool call(s)provider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active188mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-31205mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)194mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)180msprovider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active208mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-31220mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)147mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)190msprovider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active59mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3182mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)60mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)62msprovider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active140mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-31164mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)152mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)149msprovider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active60mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3181mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)75mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)79msprovider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active78mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3183mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)82mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)68msprovider_lookupprovider 4753: NPI 1821452756 (individual, 207R00000X) active85mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3167mscode_lookupHCPCS G0008: Administration of influenza virus vaccine (active)60mscode_lookupCPT S90658: Synthetic Influenza Vaccine (active)73ms
eligibility7 tool call(s)eligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-31291mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-31171mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3155mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-31144mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3163mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3163mseligibility_lookupmember 8412: enrolled in plan 28 (self) on 2025-12-3154ms
coding_edits21 tool call(s)ncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-31211msmue_checkno MUE rule for G0008 on 2025-12-31164msmue_checkno MUE rule for S90658 on 2025-12-31220msncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-31197msmue_checkno MUE rule for G0008 on 2025-12-31117msmue_checkno MUE rule for S90658 on 2025-12-31167msncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-3165msmue_checkno MUE rule for G0008 on 2025-12-3183msmue_checkno MUE rule for S90658 on 2025-12-3179msncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-31140msmue_checkno MUE rule for G0008 on 2025-12-31127msmue_checkno MUE rule for S90658 on 2025-12-31148msncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-3164msmue_checkno MUE rule for G0008 on 2025-12-3163msmue_checkno MUE rule for S90658 on 2025-12-3183msncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-3168msmue_checkno MUE rule for G0008 on 2025-12-3171msmue_checkno MUE rule for S90658 on 2025-12-3168msncci_checkno NCCI PTP rule for G0008+S90658 on 2025-12-3182msmue_checkno MUE rule for G0008 on 2025-12-3180msmue_checkno MUE rule for S90658 on 2025-12-3180ms
pricing4 tool call(s)fee_schedule_lookupno fee schedule line for G0008 on 2025-12-3176msfee_schedule_lookupno fee schedule line for S90658 on 2025-12-3172msfee_schedule_lookupno fee schedule line for G0008 on 2025-12-3172msfee_schedule_lookupno fee schedule line for S90658 on 2025-12-3175ms
Review gate decisions (5)
pend_to_humanpayby
coding_edits · conf 0.952026-04-25 15:00:07confidence_meets_thresholddollar_exceeds_caprules_verified_by_agent_tool_callsno_risk_flags
pend_to_humanpayby
disposition · conf 0.952026-04-25 18:27:15confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
pend_to_humanpayby
disposition · conf 0.952026-04-25 19:33:06confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
pend_to_humanpayby
disposition · conf 0.952026-04-25 19:34:40confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
pend_to_humanpayby
disposition · conf 0.952026-04-25 19:54:57confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: deniedClaim
238396
Member
8412
Provider
4753
Date(s) of Service
2025-12-31
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| G0008 | $1243.62 | $687.80 | $555.82 | $0.00 | $687.80 |
| S90658 | $831.31 | $444.27 | $387.04 | $0.00 | $444.27 |
| Totals | $2074.93 | $1132.07 | $942.86 | $0.00 | $1132.07 |
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 2026-04-25 19:54:57 per policy 1.