Member
8457
Billing provider
3690
DOS
2024-10-22
DB status
paid
Total charge
$315.59
Allowed
$142.82
Paid
$114.56
Member resp.
$28.26
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $315.59 | $142.82 | $114.56 |
Diagnoses: F17.210*
Agent chain trace
intake_validator4 tool call(s)provider_lookupprovider 3690: NPI 1225659089 (individual, 208000000X) active171mseligibility_lookupmember 8457: enrolled in plan 23 (self) on 2024-10-22212mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)216mscode_lookupICD-10-CM F17.210: Nicotine dependence cigarettes uncomplicated (active)202ms
eligibility1 tool call(s)eligibility_lookupmember 8457: enrolled in plan 23 (self) on 2024-10-22136ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2024-10-22174msncci_checkno NCCI PTP rule for S99213+S99213 on 2024-10-22180ms
pricing1 tool call(s)fee_schedule_lookupS99213 on 2024-10-22: preferred $233.03 (Commercial HMO 2024); 3 match(es) total239ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.952026-04-26 00:08:01confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
240041
Member
8457
Provider
3690
Date(s) of Service
2024-10-22
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $315.59 | $142.82 | $172.77 | $114.56 | $28.26 |
| Totals | $315.59 | $142.82 | $172.77 | $114.56 | $28.26 |
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 00:08:01 per policy 1.