Member
9529
Billing provider
6506
DOS
2025-12-27
DB status
denied
Total charge
$316.08
Allowed
$150.34
Paid
$0.00
Member resp.
$150.34
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $316.08 | $150.34 | $0.00 |
Diagnoses: J06.9*
Agent chain trace
intake_validator4 tool call(s)provider_lookupprovider 6506: NPI 1982794988 (individual, 207R00000X) active195mseligibility_lookupmember 9529: enrolled in plan 18 (self) on 2025-12-27108mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)190mscode_lookupICD-10-CM J06.9: Acute upper respiratory infection unspecified (active)191ms
eligibility1 tool call(s)eligibility_lookupmember 9529: enrolled in plan 18 (self) on 2025-12-27176ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2025-12-27191msncci_checkno NCCI PTP rule for S99213+S99213 on 2025-12-27190ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S99213 on 2025-12-27196ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.602026-04-26 01:50:57confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: deniedClaim
278246
Member
9529
Provider
6506
Date(s) of Service
2025-12-27
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $316.08 | $150.34 | $165.74 | $0.00 | $150.34 |
| Totals | $316.08 | $150.34 | $165.74 | $0.00 | $150.34 |
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 01:50:57 per policy 1.